UC-NRLF 


B    3    im    133 


..lU.ENT  OF   CIVIL.   ENGINEISFUIHC 
-RKEL.eY,  CAUFORNIA 


I  r 


Civl  1   Enp;ineerin^   Dept . 


UNIVERSITY  OF  CALIFORNIA 

^EFARTMENT  OF  CIVIL  ENGINEERlS<£ 

BERKELEY,  CALIFORNIA 


PUBLIC  HEALTH 
SURVEYS 

WHAT  THEY  ARE     HOW  TO  MAKE  THEM 

HOW  TO  USE  THEM 


BY 

MURRAY  P.  HORWOOD,  M.  S.,  Ph.  D. 

Instructor,  Department  of  Biology  and  Public  Healthy 
Massachusetts  Institute  of  Technology 


WITH  A  FOREWORD 
BY 

WILLIAM   T.   SEDGWICK 

AND  AN  INTRODUCTION 
BY 

GEORGE  C.  WHIPPLE 


NEW  YORK 

JOHN  WILEY  &  SONS,  Inc. 

London:    CHAPMAN  &  HALL,   Limted 

1921 


^6 


Engineering 
Li^i-ary 


Copyright,  1921, 

BY 

MURRAY  P.   HORWOOD 


TECHNICAL  COMPOSITION  CO. 
CAMBRIDGE,    MA88.,    U.   8.   A. 


To 

My  Wife 

LOUISE  PEIRCE  HORWOOD 


r  "7  n  n  1'  A 


PREFACE 


The  purpose  of  this  book  is  to  serve  as  a  guide  to  all  those 
who  contemplate  making  public  health  surveys.  It  should 
therefore  appeal  to  public  health  surveyors,  health  officers, 
boards  of  health,  sanitary  inspectors,  socio-sanitary  and  wel- 
fare workers,  to  students  in  schools  of  public  health,  and  to 
investigators  who  may  be  interested  in  any  particular  portion 
of  the  book.  The  author  has  tried  to  foresee  as  far  as  pos- 
sible most  of  the  problems  and  difficulties  which  might  arise 
during  the  progress  of  a  public  health  survey,  and  to  sug- 
gest a  solution.  This  has  been  done  at  the  risk  of  over- 
emphasizing details.  Those  who  have  ever  been  teachers 
know  the  importance  of  detailed  instruction.  Since  the  book 
is  to  serve  as  a  guide,  it  was  considered  wiser  not  to  omit 
details,  even  those  that  would  be  obvious  to  the  average 
person. 

In  considering  the  various  subjects  that  are  included  in 
a  public  health  survey,  it  was  deemed  desirable  to  begin 
each  chapter  with  a  brief  description  of  what  the  ideal 
condition  should  be.  This  introductory  discussion  should 
facilitate  the  understanding  and  fair  appraisal  of  the  local 
situation.  It  should  also  serve  to  increase  the  value  of  the 
book  as  a  text-book.  The  questions  which  follow  the  dis- 
cussion should  prove  helpful  in  gathering  the  specific  infor- 
mation that  is  required. 

It  is  obvious  that  the  book  cannot  meet  the  needs  of  every 

possible  situation  that  may  exist  in  every  city,  both  large 

and  small.     In  some  cases  the  book  will  prove  to  be  too 

extensive  in  scope  and  depth,  while  in  others  it  will  doubt- 
ill 


iv  PREFACE 

• 

less  prove  to  be  inadequate  and  even  superficial.  It  is  the 
author's  hope  that  in  most  cases  the  book  will  serve  as  a 
useful  guide,  and  that  in  the  very  small  cities  the  unneces- 
sary portions  will  be  omitted,  while  in  the  very  large  cities 
the  scope  of  the  book  will  be  augmented  to  meet  the  needs 
of  the  occasion.  The  surveyor  must  be  able  to  choose  what 
is  of  value  to  him  and  to  omit  that  which  is  of  little  or  no 

value. 

There  are  many  to  whom  the  author  is  grateful  for  various 
services  in  the  preparation  of  this  book,  and  to  whom 
acknowledgment  should  be  made.  Particular  thanks  are 
due  to  Professor  W.  T.  Sedgwick,  recently  deceased,  for  his 
numerous  suggestions,  interest,  inspiration,  mature  advice, 
and  for  the  Foreword  he  so  kindly  prepared.  Special  thanks 
are  also  due  to  Professor  G.  C.  Whipple,  of  Harvard  Univer- 
sity, for  writing  the  Introduction  and  for  permission  to 
quote  a  thorough  enumeration  and  scientific  arrangement  of 
the  factors  considered  in  a  public  health  survey.  Thanks 
are  also  due  to  Mr.  Jules  Schevitz,  Secretary  of  the  Oklahoma 
Pubhc  Health  Association,  for  reading  the  chapters  deahng 
with  the  organization  for  a  survey  and  the  methods  em- 
ployed, and  the  chapter  on  tuberculosis;  to  Professor  Robert 
Spurr  Weston,  for  criticizing  the  chapters  on  water-supply, 
sewage-disposal,  and  refuse-disposal;  to  Professor  S.  C. 
Prescott,  of  the  Massachusetts  Institute  of  Technology,  for 
readhig  the  chapter  on  milk-supply;  to  Mr.  Joseph  Herz- 
stein,  formerly  Executive  Secretary  of  the  Rensselaer  County 
Tuberculosis  Association  in  New  York  State,  for  reading  and 
criticizing  the  chapters  on  school  hygiene  and  school  sani- 
tation; and  to  Professor  C.-E.  A.  Winslow,  of  the  Yale  Medical 
School,  for  reading  the  chapter  on  the  organization  and 
activities  of  the  health  department. 

Finally,  I  desire  to  acknowledge  my  great  debt  to  my 
wife,  without  whose  aid  the  pubhcation  of  this  book  would 


PREFACE  V 

have  been   impossible.     Critic,    councillor   and   help-mate, 
she  has  had  a  very  important  part  in  bringmg  the  book  to 

its  present  state.  yTr^T^^^Tr\nT\ 

MURRAY  P.   HORWOOD. 


Cambridge,  Mass. 
March,  1921. 


CONTENTS 


PAGE 

Preface v 

J^'OREWORD xi 

Introduction xv 

CHAPTER 

I.    General  Information   about   Public   Health   Sur- 
veys    1 

II.   Organizing  a  Community  for  a  Public  Health  Sur- 
vey   10 

III.  Methods  Employed   in   Making    a   Public   Health 

Survey 28 

IV.  General  Information  about  the  Community 38 

V.    Water-Supply 44 

VI.    Drainage,  Sewerage  and  Sewage-Disposal 78 

VII.    Collection  and  Disposal  of  Refuse 102 

VIII.    Milk-Supply 125 

IX.   Inspection    of    Restaurants,    Lunch    Rooms    and 

Food-Stores 156 

X.   Housing 170 

XI.   School  Sanitation 189 

XII.   School  Hygiene 209 

XIII.  Organization   and   Activities   of   the   Health   De- 

partment    223 

XIV.  Hospital  Facilities 242 

XV.   Tuberculosis 253 

XVI.   Vital  Statistics 275 

XVII.   Analysis  of  City  Budget 298 

XVIII.    The  Preparation  of  the  Report 310 

XIX.    Recommendations  from  other  Survey  Reports.  .  .  .  324 

XX.    Methods  of  Obtaining   Results   from  the   Public 

Health  Survey 351 

XXI.   The  Value  of  the  Public  Health  Survey  in  the 

Public  Health  Campaign 359 

Bibliography 371 

Index  of  Subjects 385 

•  • 

Vll 


FOREWORD* 

BY 

William  T.  Sedgwick 

Professor  of  Biology  and  Public  Health,  Massachusetts 

Institute  of  Technology; 

Member,  Public  Health  Council,  State  Department  of 

Public  Health  of  Massachusetts;  etc. 

That  proverb  Avhich  advises  us  to  look  before  we  leap  is 
nowhere  more  applicable  than  in  public  health  undertakings. 
The  great  sanitary  awakening  which  characterized  the  first 
half  of  the  nineteenth  century  terminated  ages  of  ignorance 

*  The  Foreword  by  Professor  Sedgwick  was  received  by  the  author 
December  31,  1920.  Professor  Sedgwick  died  suddenly  on  January  25, 
1921.     The  Foreword  is  probably  the  last  thing  he  wrote  for  pubhcation. 

Professor  Sedgwick,  who,  a  few  years  ago,  was  called  by  Dr.  Allan 
J.  McLaughlin,  "Dean  of  the  public  health  profession  in  the  United 
States,"  was  a  pioneer  in  the  development  of  sanitary  science  and 
public  health.  For  almost  forty  years,  men  and  women  from  all  parts 
of  the  world  came  to  study  under  him  and  to  receive  the  inspiration 
and  vision  which  were  to  fill  their  lives  with  the  public  health  mission- 
ary spirit,  which  they  were  to  carry  all  over  the  world.  No  one  who 
came  in  contact  with  Professor  Sedgwick,  either  as  student  or  co- 
worker, ever  failed  to  recognize  his  charming  personality,  his  magnetic 
influence  over  men,  and  his  dominating  spirit  on  all  occasions.  "Men 
turned  to  him  as  to  the  sun."  A  constant,  ever-ready  guide  and  adviser, 
paternal  in  his  interest  and  affection  for  his  pupils,  those  who  had  the 
good  fortune  to  study  under  him  became  part  of  a  great  family,  devoted 
to  the  man  and  to  the  cause  which  he  espoused.  Professor  Sedgwick 
was  a  champion  of  the  truth.  For  him,  the  whole  world  was  his  labora- 
tory. His  interests  were  wide  and  numerous.  He  was  indeed  a  man 
of  rare  culture,  and  a  public  servant  in  the  best  sense.  His  spirit  will 
hve  in  the  minds  of  those  who  knew  him  intimately,  and  he  will  always 
be  remembered  with  tenderest  affection.  To  the  author,  Professor 
Sedgwick  was  teacher,  friend  and  inspirer. 

ix 


X  FOREWORD 

and  neglect  of  h3'o;iene  and  public  health  reaching  far  back 
through  primitive  and  prehistoric  times  to  the  very  begin- 
nings of  the  human  race.  It  was  followed,  in  the  second 
half  of  the  nineteenth  century,  by  the  marvelous  discoveries 
of  Pasteur  and  Koch  concerning  the  parasitic  origin  of  the 
communicable  diseases,  whereupon  popular  attention  began 
to  be  focused  upon  the  improvement  of  the  health  of  indi- 
viduals and  of  communities.  Many  of  the  latter  began 
forthwith  to  set  their  houses  in  order,  seeking  for  better  and 
•more  copious  water-supplies,  better  drainage,  and  better 
milk-supplies,  and  providing,  for  the  first  time,  for  public 
parks,  playgrounds,  baths,  gymnasia  and  other  costly  appli- 
ances. More  recently,  a  great  wave  of  popular  bulletins, 
circulars,  posters,  pamphlets,  reports,  and  newspaper  articles 
has  helped  to  create  a  general  demand  for  better  municipal 
sanitation  and  better  pubhc  health  administration.  In  this 
wave  of  popular  enthusiasm  there  is  much  to  rejoice  over, 
but  also  much  to  be  deplored  of  error,  of  waste,  and  espe- 
cially in  the  masquerading  of  half-truths  as  estabhshed 
verities. 

The  principal  break-water  against  this  flood  of  sometimes 
misdirected  popular  enthusiasm,  and  the  sure  guide  to  wise 
municipal  endeavor  in  this  field,  is  the  public  health  survey, 
by  means  of  which  it  becomes  easy  for  a  community  to  dis- 
cover with  comparative  certainty  the  actual  facts  relating  to 
its  sanitary  conditions  and  its  sanitary  needs,  or,  in  other 
words,  to  look  before  it  leaps,  and  hence  to  advance  safely, 
sanely,  and  scientifically  toward  rational  and  economical 
pubhc  health  improvements. 

The  writer  has  watched  with  keen  interest  the  develop- 
ment of  the  theory  and  practice  —  the  science  and  the  art 
—  of  Public  Health  Surveying,  and  all  the  more,  because 
two  of  his  former  pupils  have  played  important  parts  in  the 
development  of  the  subject  in  the  United  States,  namely, 
Mr.  Franz  Schneider,  Jr.,  who  for  some  years  made  thor- 


FOREWORD  XI 

oughgoing  Sanitary  Surveys  for  the  Russeil  Sage  Foundation, 
and,  more  recently,  Mr.  Horwood,  the  author  of  the  present 
volume. 

Some  of  Mr.  Horwood's  surveys  are,  I  believe,  the  first 
which  have  set  out  to  cover  the  urban  population  of  an  en- 
tire American  State,  and  inasmuch  as  I  have  been  able  to 
follow  somewhat  closely  his  methods  and  results,  I  believe 
that  in  the  work  which  he  now  presents  to  the  public  Mr. 
Horwood  will  be  doing  for  all  who  are  interested  in  Public 
Health  or  community  welfare  a  notable  service. 

The  sub-title  of  the  book  explains  clearly  its  place  and 
purpose;  and  those  who  are  interested  in  the  public  health 
and  who  learn  through  its  pages  exactly  what  public  health 
surveys  are,  as  well  as  how  to  make  and  how  to  use  them, 
will  be  grateful  to  the  author  for  his  painstaking  labor.  So 
also  will  all  students  and  workers  who  value  a  safe  guide 
into  an  immense  and  important  field  of  the  public  service. 


INTRODUCTION 

BY 

George  C.  Whipple 
Professor  of  Sanitary  Engineering,  Harvard  Engineering  School 

Cambridge,  Massachusetts 

Sanitary  surveys,  or  public  health  surveys,  as  the  author 
has  chosen  to  call  them,  are  a  logical  part  of  the  present-day 
movement  to  improve  the  health  of  the  world.  They  find 
their  greatest  use  in  countries  where  ignorance  of  sanitation 
prevails,  but  they  are  not  without  value  in  the  more  edu- 
cated communities  where  civihzation  stands  at  its  highest. 
Reforms  in  one  field  or  another  are  needed  from  time  to 
time  in  all  places,  for  sanitation,  like  civilization,  moves  for- 
ward by  jerks. 

Some  General  Principles 

Reforms  usually  come  about  as  the  result  of  some  calamity. 
Water  filters  are  often  built  as  a  result  of  typhoid  fever  epi- 
demics. A  conflagration  brings  improvement  in  fireproofing. 
Floods  are  followed  by  the  construction  of  breakwaters  and 
works  for  river  control.  People  learn  by  experience,  by 
suffering.  The  '^university  of  hard  knocks"  is  one  in 
which  we  are  all  classmates.  The  wise  way  is  to  substitute 
foresight  for  suffering  and  bring  about  needed  reforms  before 
calamities  happen.  Preventive  measures  must  be  based  on 
facts,  and  one  of  the  prime  objects  of  a  sanitary  survey  is  to 
reveal  the  weak  spots  and,  by  studying  all  of  the  elements 
of  the  situation,  to  ascertain  how  impending  dangers  may  be 
avoided  by  timely  action. 

Prevention  of  disease  and  disaster  is  not  the  only  object 

of  a  sanitary  survey.     Health  has  a  positive  side.     Health 

may  be  fostered  in  ways  that  are  pleasant.     Joy  can  be 

xiii 


xiv  INTRODUCTION 

put  into  life  in  many  ways  by  taking  advantage  of  oppor- 
tunities. Sunlight  in  winter,  shade  in  summer,  skylight 
and  fresh  air  can  often  be  obtained  to  a  far  greater  extent 
than  at  present  by  giving  attention  to  little  details,  by 
rectifying  bad  conditions  unnoticed  because  familiar.  Sani- 
tary surveys  call  attention  to  the  overlooked  opportunities 
in  public  health. 

Sanitary  surveys  furnish  facts  which  should  become  guides 
in  estimating  the  relative  values  of  different  proposed  re- 
forms. They  should  furnish  the  basis  of  economical  expen- 
ditures of  public  money.  They  should  indicate  what 
expenses  ought  to  be  public  and  what  ought  to  be  private. 
The  world,  up  to  the  time  of  the  Great  War,  had  been  living 
at  an  extravagant  pace.  Luxury  was  the  ruling  standard. 
The  inevitable  reaction  is  coming.  Thrift  must  replace 
luxury,  —  and  if  we  read  history  aright,  thrift  will  bring 
more  happiness  than  luxury  has  given.  Even  in  health 
administration,  states  and  cities  have  often  been  extravagant 
and  reductions  of  appropriations  are  sure  to  come.  It  must 
be  remembered,  however,  that  parsimony  is  not  economy. 
If  appropriations  are  to  be  cut  the  cutting  must  be  done 
wisely.  Some  cities  even  now  spend  far  too  Uttle  for  public 
health.  Sanitary  surveys  help  to  furnish  the  facts  for  ad- 
justing pubhc  expenses. 

Sanitary  surveys  have  an  educational  value.  Most  citi- 
zens are  quite  ignorant  of  the  conditions  existing  in  their 
own  cities.  They  do  not  know  how  ''the  other  half  Hves" 
or  how  the  other  half  dies.  Knowledge  makes  them  better 
citizens.  The  more  the  citizens  know  about  their  health 
conditions  the  better  will  be  the  public  administration  of 
their  health  department.  Sanitary  surveys  give  oppor- 
tunity for  extending  common  knowledge  of  accepted  prin- 
ciples of  health. 


INTRODUCTION  XV 

Financial  and  Governmental  Problems 

All  that  has  just  been  said  of  sanitary  surveys  —  their 
use  in  preventing  ills,  in  enhancing  health  in  pleasurable 
ways,  in  regulating  economies  and  encouraging  education  — 
is  equally  true  of  other  branches  of  governmental  activities 
and  public  works.  Sanitary  surveys  tie  in  with  the  city 
planning  movement,  which  seeks  to  improve  the  physical 
conditions  of  cities  so  as  to  make  them  more  suitable  to  the 
needs  of  the  citizens,  more  efficient,  and  more  beautiful. 

Cities  are  becoming  larger  as  a  result  of  the  enormous 
use  of  power  for  production  and  transportation.  The  larger 
the  city  the  more  difficult  and  more  expensive  its  govern- 
ment. If  large  cities  are  to  be  successfully  governed  on 
democratic  principles,  there  must  be  more  popular  knowledge 
of  what  the  government  is  doing  and  what  it  ought  to  do. 
Governments  use  what  is  called  the  police  power  to  prevent 
public  injury  to  health,  safety  and  morals.  As  cities  grow 
in  size  this  police  power  has  to  be  exercised  more  drastically; 
individuals  must  be  more  restricted  in  their  deeds  and  the 
use  of  the  property  lest  they  injure  many  people.  Govern- 
ments use  their  taxing  power  and  their  rights  of  eminent 
domain  to  bring  about  public  benefits.  Public  benefits 
have  to  be  paid  for  by  the  public.  These  public  "improve- 
ments" are  more  necessary  in  large  cities,  and  in  these  cities 
the  tax-rates  and  the  public  debts  are  rising  at  an  alarming 
rate,  even  when  compared  on  a  per  capita  basis.  As  long 
as  the  cities  continue  to  grow  the  pinch  is  not  felt,  but  the 
time  is  ahead  when  the  rates  of  growth  of  many  American 
cities  will  materially  fall  off  and  when  the  financial  problem 
will  overtop  all  others,  public  health  problems  included. 

It  is  important  for  public  health  administrators  to  keep 
the  financial  factor  well  to  the  front,  and  to  carefully  dis- 
criminate between  actions  which  come  within  the  scope  of 
the  pohce  power  and  those  which  belong  to  the  province  of 


xvi  INTRODUCTION 

eminent  domain  and  the  taxing  power.  There  is  a  difference 
between  measures  which  prevent  pubhc  damage  and  those 
which  confer  a  pubhc  benefit.  There  is  a  difference  between 
pubhc  health  and  the  collective  result  of  private  health,  —  a 
difference  between  mass  action  and  collective  action.  Sani- 
tary surveys  well  conducted  and  with  these  principles  clearly 
set  forth  in  a  concrete  way  will  start  a  community  to  thinking. 

The  Survey  Itself 

The  basic  principle  of  the  sanitary  survey  is  seeing  with 
trained  eyes.  Surveying,  in  the  true  sense,  is  not  the  mere 
collection  of  data,  not  the  accumulation  of  vast  arrays  of 
statistics,  but  the  scientific  scrutiny  of  the  essential  facts 
and  factors  which  may  influence  the  health  of  the  people, 
the  preparation  of  a  record  of  these  things  for  use  by  the 
officials  concerned  and  the  publication  of  such  portions  of 
the  record  as  will  tell  the  people  the  main  facts  about  the 
health  condition  of  their  community,  the  wrongs  which 
need  to  be  righted,  and  the  improvements  which  need  to  be 
made. 

Novices  who  undertake  sanitary  surveys  are  inclined  to 
do  too  much,  to  lack  discrimination  in  the  data  which  they 
collect.  They  are  also  liable  to  make  too  many  detailed 
recommendations  in  fields  which  call  for  advice  from  special- 
ists. Of  many  a  report  it  may  be  fairly  said,  to  quote  from 
the  cowboy's  epitaph,  ''Poor  fellow,  he  tried  to  do  too  much, 
and  he  done  it."  Schedules  of  the  data  set  up  as  standards 
of  procedure  should  not  be  followed  too  closely.  Such 
schedules  are  usually  made  inclusive  in  order  to  call  atten- 
tion to  important  items  liable  to  be  overlooked.  It  must 
be  remembered  that  the  data  essential  in  one  place  may  be 
superfluous  in  another  place.  Facts  which  are  of  vital  con- 
cern in  Panama  may  be  of  no  significance  in  Canada.  In 
collecting  data  one  should  keep  in  mind  the  objects  for  which 
the  survey  is  being  made.     Catch-all  work  should  not  be 


.INTRODUCTION  xvii 

encouraged.  There  must  be  economy  in  the  survey  and 
the  surveyor  must  himself  have  an  appreciation  of  relative 
values  and  of  the  cost  of  his  own  work. 

Standardization  of  form  is,  however,  desirable.  This  is 
necessary  in  order  that  the  conditions  found  in  one  place 
may  be  compared  with  those  found  somewhere  else.  It  is 
hard  to  compare  the  costs  of  water  filtration  expressed  in 
one  place  as  so  many  dollars  per  million  gallons  and  some- 
where else  as  so  many  cents  per  thousand  cubic  feet.  It 
is  hard  to  compare  crude  death-rates  in  one  place  with  cor- 
rected death-rates  in  another  place.  It  is  hard  to  compare 
any  two  things  unless  the  unit  of  measure  is  the  same.  If 
any  two  sanitary  surveys  made  within  the  last  ten  years 
are  compared  with  each  other,  it  will  be  found  that  they 
differ  in  many  of  the  units  used. 

Strictly  speaking,  sanitary  surveys  ought  to  be  made  only 
by  persons  who  have  had  a  broad  experience  and  who  are 
familiar  with  all  of  the  many  fields  which  have  to  be  covered. 
Such  persons  are  difficult  to  find.  ^'Seeing  with  trained 
eyes"  means  something.  A  good  many  persons  who  have 
studied  public  health  do  not  have  sharp  eyes  or  a  genius 
for  getting  at  facts,  and  a  good  many  persons  who  are  keen 
eyed  and  endowed  with  the  detective  faculty  do  not  have  a 
sound  scientific  basis  for  their  investigation.  The  one  class 
overlooks  important  health  factors,  the  other  gets  a  com- 
munity stirred  up  needlessly  and  cries  ''Wolf"  when  there  is 
no  wolf.  In  some  of  the  American  schools  of  public  health 
the  making  of  a  sanitary  survey  of  some  small  town  is  re- 
quired as  a  part  of  the  course  of  study.  It  is  excellent 
practice  for  the  students,  but  sometimes  hard  on  the  town. 
No  serious  damage  results,  however,  as  the  results  are  not 
published,  while  it  often  happens  that  the  survey  proves  of 
considerable  value  to  the  local  health  officer.  Practically, 
many  sanitary  surveys  are,  and  of  necessity  have  to  be, 
made  by  persons  who  have  had  relatively  little  practical 


xviii  INTRODUCTION 

experience,  although  they  may  know  the  general  principles 
of  hygiene  and  sanitation.  Such  persons  ought  to  find  the 
present  volume  suggestive  and  helpful. 

As  a  rule  sanitary  engineers  are  better  fitted  for  making 
a  survey  than  physicians,  as  their  training  makes  them  more 
familiar  with  statistical  matters,  with  maps,  plans  and  loca- 
tions, and  has  accustomed  them  to  generalize  from  large 
accumulations  of  data.  Engineers  are  by  experience  accus- 
tomed to  looking  at  large  projects  in  large  ways.  The  ex- 
perience of  physicians  is  a  more  personal  experience.  The 
one  operates  upon  individual  patients;  the  other  operates 
upon  the  community.  Public  health  is  a  mass  phenomenon 
and  must  be  studied,  diagnosed  and  treated  as  such.  Of 
course,  there  are  notable  exceptions,  —  physicians  who  can 
see  beyond  their  sick-rooms  and  who  are  endowed  with  a 
sense  of  mass;  but  these  exceptions  only  prove  the  rule. 
Some  excellent  sanitary  surveys  have  been  made  by  phy- 
sicians and  by  committees  of  medical  men. 

The  sanitary  survey  covers  so  wide  a  field  that  it  is  always 
wise  to  have  the  findings  in  each  field  reviewed  by  a  person 
competent  to  criticize  before  they  are  made  public.  The 
author  has  wisely  emphasized  the  need  of  cooperation  of 
local  authorities  in  making  surveys.  The  person  called  in 
from  the  outside  to  make  the  survey  of  a  place  must  be 
something  more  than  a  gad-fly,  stinging  sleepy  departments 
into  action;  he  must  have  a  helpful  spirit  and  be  able  to 
offer  real  constructive  ideas;  and  he  must  have  that  rare 
quality  of  knowing  how  to  adapt  scientific  methods  to  local 
conditions  and,  as  the  author  says,  must  be  tactful  in  his 
investigation. 

Reports  of  Surveys 
Sanitary  surveys  are  made  partly  fo     purposes  of  his- 
torical record,  but   chiefly  that  unknown  defective  health 
conditions   may   be   ascertained.     Pubhcity   of   the   results 


INTRODUCTION  xix 

may  do  good  and  it  may  do  harm.  Nothing  in  connection 
with  the  sanitary  survey  is  more  dehcate  or  requires  greater 
tact  than  the  matter  of  making  pubhc  the  results  of  the 
survey.  A  few  principles  may  be  laid  down,  —  but  to  a 
large  extent  pubhcity  is  a  matter  which  must  be  thought 
out  for  each  case. 

In  the  first  place  it  is  not  necessary  that  the  surveyor  put 
all  of  his  accumulated  facts  into  his  pubhc  report.  Printing 
costs  money  and  reports  do  not  impress  the  public  by  their 
bulk  but  by  their  meat.  Collected  data  should  not  be  thrown 
away,  but  often  a  well  indexed  and  bound  copy  of  type- 
written sheets  filed  with  the  city  clerk  as  an  official  record, 
with  a  duplicate  placed  in  the  public  library,  will  answer 
every  reasonable  purpose.  The  printed  report  should  con- 
tain the  essential  data,  well  boiled  down,  and  arranged  for 
convenient  study  and  comparison. 

Reports  of  sanitary  surveys  are  usually  intended  for  the 
use  of  non-technical  readers.  Hence,  the  style  of  writing 
should  be  simple,  clear  and  direct.  Technical  terms,  if 
used,  should  be  explained.  Technical  details,  if  printed, 
should  be  set  apart,  perhaps  in  an  appendix,  so  as  not  to 
confuse  the  reader  in  his  perusal  of  the  main  report.  To 
a  considerable  extent  the  report  of  a  sanitary  survey  gives 
opportunity  to  enlighten  the  public  on  many  scientific 
matters,  but  to  do  this  successfully  requires  a  skillful  use  of 
the  English  language  as  well  as  a  knowledge  of  science. 

SensationaUsm  should  be  avoided.  A  survey  should  result 
in  nouns  rather  than  adjectives.  If  sanitary  conditions  are 
bad,  a  plain  statement  of  the  conditions  will  indicate  their 
badness.  Published  documents  sometimes  fly  far.  ''Boys 
flying  kites  pull  in  their  white  winged  birds;  but  you  can't 
do  that  when  you're  flying  words."  Citizens  should  be  told 
the  truth  about  insanitary  conditions,  but  if  it  can  be  told 
to  them  without  their  neighbors  knowing  too  much  about 
it,  so  much  the  better  for  the  reputation  of  their  city  and  so 


XX  INTRODUCTION 

much  the  more  Hkely  that  the  people  will  cooperate  in 
remedying  the  bad  conditions.  There  is  always  danger  of 
introducing  too  much  ''realism"  into  the  reports  of  a  sani- 
tary survey  and  of  failing  to  set  forth  possible  ideals  of  local 
attainment.  If  a  public  water  supply  is  found  defective  in 
Uttle  things,  it  is  far  better  to  go  to  the  water  superintendent 
and  the  city  government  and  have  the  matter  corrected 
quietly  than  it  is  to  put  the  findings  into  the  local  paper. 
Publicity  which  follows  such  an  action  and  tells  of  good 
accomplished  helps  the  city  in  the  eyes  of  the  world;  but 
publicity  which  sets  forth  the  fault  uncorrected  injures  the 
city's  good  name.  If  no  action  is  taken  after  the  fault  has 
been  uncovered,  local  pliblicity  may  be  rightly  resorted 
to  in  the  interest  of  the  public  good;  and  if  the  pubUc, 
knowing  the  fault,  refuses  to  correct  it,  wide  publicity  is 
justified  and  the  city  deservedly  held  up  to  scorn.  Some 
kinds  of  faulty  hygiene  depend  for  their  correction  upon  the 
action  of  individuals.  For  example,  in  the  care  of  privies, 
in  the  household  care  of  garbage,  and  in  many  of  the  details 
of  bad  housing,  publicity  is  the  most  effective  means  of 
teaching  provided  that  it  be  not  personal. 

While  it  is  desirable  to  secure  public  interest  in  the  making 
of  a  sanitary  survey  and  while  it  is  important  that  the 
officials  concerned  should  have  knowledge  of  what  is  going 
on,  there  is  danger  that  too  much  local  publicity  may  be 
detrimental  to  the  work.  The  surveyor  is  not  to  be  regarded 
as  a  detective  or  spy,  nor  as  a  prodigy  of  sanitary  skill,  but 
merely  as  a  well  qualified  engineer,  called  upon  to  look  over 
the  health  condition  of  a  city,  just  as  a  well  qualified  physi- 
cian is  called  upon  to  look  over  a  man's  physique  to  see  if  he 
is  in  sound  condition.  The  man  already  knows  something 
about  his  own  health,  and  the  city  knows  something  about 
its  own  sanitary  condition,  but  both  sorts  of  surveys  are 
useful  and  worth  while. 

While  it  is  well  that  the  pubhc  should  know  about  the 


INTRODUCTION  xxi 

sanitary  conditions  of  their  own  cities  or  towns,  it  must  not 
be  forgotten  that  health  activities,  Hke  everything  else,  can 
be  carried  too  far.  Too  much  thinking  about  one's  health 
makes  a  person  morbid.  It  is  possible  for  communities  to 
get  into  the  same  condition.  After  all,  there  is  more  health 
in  the  world  than  there  is  sickness  and,  except  in  old  age, 
the  chance  of  living  is  far  greater  than  the  chance  of  dying. 
It  is  well  to  have  sanitary  surveys  made  at  reasonable  inter- 
vals and  insanitary  conditions  should  be  corrected,  but  when 
that  has  been  done  it  is  well  for  people  to  turn  their  atten- 
tion more  to  the  cultivation  of  health  in  ways  that  are 
pleasant  and  to  devote  their  energies  to  hving  normal  and 
happy  Hveo. 

Sanitary  Surveys  Not  New 

While  the  present  volume  is  perhaps  the  first  comprehen- 
sive treatment  of  the  subject  of  public  health  surveys,  the 
idea  is  by  no  means  new.  Students  would  do  well  to  examine 
the  excellent  sanitary  surveys  made  by  Sir  Robert  RawHn- 
son  in  England  between  the  years  1844  and  1851.  These 
were  pubUshed  by  the  General  Board  of  Health  of  England 
under  the  Pubhc  Health  Act.  Following  the  period  of 
sanitary  awakening,  and  setting  forth  in  detail  the  insanitary 
condition  of  many  Enghsh  cities,  they  served  as  the  basis  of 
some  of  the  most  important  and  far-reaching  health  laws 
ever  enacted. 

A  survey  of  Boston  was  made  and  published  in  1845  by 
Lemuel  Shattuck,  and  this  was  followed  in  1850  by  the 
Report  of  the  Massachusetts  Sanitary  Commission,  one  of 
the  most  remarkable  pubUc  health  documents  ever  pubhshed 
in  America.*  No  better  arguments  in  favor  of  sanitary 
surveys  were  ever  set  forth  than  in  the  fifty  "state  and 
municipal  measures  recommended 'J  by  Lemuel  Shattuck  in 

*  Students  can  find  this  reprinted  in  "  State  Sanitation,"  Vol.  I,  pub- 
lished by  the  Harvard  University  Press. 


XXU  INTRODUCTION 

this  report,  which  paved  the  way  for  the  organization  of  the 
Massachusetts  State  Board  of  Health. 

One  of  the  most  interesting  of  recent  developments  of 
sanitary  surveying  is  the  proposed  undertaking  of  the 
League  of  Red  Cross  Societies.*  An  attempt  will  be  made 
by  this  great  organization  to  secure  reports  of  sanitary 
surveys  from  many  cities  in  all  parts  of  the  world,  with  the 
major  data  collected  according  to  standardized  schedules. 
In  the  case  of  the  surveys  made  in  countries  where  the 
people  are  ignorant  of  what  good  sanitation  is,  the  investiga- 
tion will  be  accompanied  by  educational  propaganda  in  the 
interest  of  better  living  conditions.  The  League  of  Red 
Cross  Societies  is  thus  establishing  a  splendid  precedent,  — 
one  which  is  worthy  of  being  followed  wherever  sanitary 
surveys  are  made,  —  namely,  that  of  follo^\^ng  a  paraphrase 
of  the  scriptural  injunction,  ''As  ye  go,  teach !^' 

*  Described  in  the   International  Journal  oj  Public  Health.  Vol.  1, 
No.  1,  1920. 


5       >        3    5 


Public  Health  Surveys 


What  They  Are 
How  to  Make  Them 
How  to  Use  Them 


CHAPTER  I 

GENERAL   INFORMATION   ABOUT   PUBLIC 
HEALTH   SURVEYS 

Need  for  Standardizing  Public  Health  Surveys.  —  During 
the  past  ten  years,  a  new  force  in  public  health  progress, 
generally  called  the  public  health  survey,  has  been  developed 
in  this  country.  Just  what  a  public  health  survey  is,  and 
what  its  scope  should  be,  have  not  been  generally  clear. 
The  methods  that  have  been  followed  in  making  surveys 
have  rarely  been  exactly  alike,  even  with  the  same  investi- 
gator. Some  surveys  have  been  very  thorough  and  wide 
in  scope,  very  complete,  and  full  of  original  work.  The 
conclusions  from  such  work  have  always  been  based  on 
facts.  Other  surveys  have  been  very  superficial,  being 
completed  in  a  few  days  at  most,  and  provide  information 
based  on  hearsay  and  not  on  personal  investigation.  Con- 
clusions from  such  surveys  are  not  really  based  on  facts,  and 
are  not  as  valuable  as  those  obtained  in  the  first  instance. 
There  are  other  surveys  which  lie  somewhere  between  these 
two  extremes,  and  accordingly  have  greater  or  less  value, 
depending  upon  the  type  which  each  approaches.  No 
attempt,  so  far  as  the  author  is  aware,  has  been  made  to 
standardize  public  health  surveys,  nor  has  there  been  much 
discussion,  if  any,  on  the  best  ways  to  proceed  in  conduct- 

1 


2        INFORMATION  ABOUT  f UBLIC   HEALTH  SURVEYS 

•  .   '     .      / 

ing  a  survey,  so  that  each  individual  has  been  compelled 
to  work  out  his  own  method,  and  his  own  salvation. 

There  have  been  surveys  of  every  description,  some  being 
extensive  in  scope,  and  some  limited  to  specific  subjects^ 
Thus,  there  have  been  tuberculosis  surveys,  housing  sur- 
veys, malaria  surveys,  hookworm  surveys,  surveys  of  pub- 
lic institutions,  such  as  schools,  hospitals,  asylums,  etc., 
typhoid  fever  surveys,  lunch  room  surveys,  sickness  sur- 
veys, water  surveys,  sanitary  surveys  in  connection  with 
water-supplies  or  sewage-disposal,  and  lastly,  general  health 
surveys.     Of  these,  the  widest  in  scope  is  the  general  health 
survey,    which   considers   all   the   factors  that   affect   the 
health  of  a  community.     There  have  been  other  surveys 
too,  both  of  public  health  interest,  and  in  fields  not  allied 
to  pubhc  health.     There  have  been  surveys  of  rural  health 
conditions,  and  pellagra  surveys.     There  have  also  been 
biological  surveys  of  states,  which  have  been  conducted 
under  the  direction  of  the  United  States  Department  of 
Agriculture.     There  have  been  surveys  of  economic  con- 
ditions, such  as  wages,  and  hours  of  emplojanent ;    there 
have  been  surveys  of  factory  conditions  that  affect  the 
health  and  welfare  of  the  worker;  there  have  been  surveys 
of  markets,  of  businesses,  of  food  supplies,  and  there  have 
been  rehgious  surveys.     In  fact,  the  survey  lends  itself  to 
almost  any  phase  of  human  endeavor  or  interest. 

Definition  of  a  Public  Health  Survey.  —  A  survey  must 
therefore  be  a  broad  thing.  It  is  a  means  of  obtaining  a 
general  view  or  broad  aspect  of  a  situation  or  a  condition; 
but  it  should  be  more  than  that.  A  general  view  is  usually 
a  superficial  view,  while  a  survey  should  give  a  deep  insight 
into  the  details  of  the  particular  situation  under  investiga- 
tion. There  are  times,  of  course,  when  the  general  super- 
ficial view  is  all  that  is  required;  but  in  a  pubHc  health 
survey,  the  work  should  be  an  investigation  and  not  merely 
a  bird's-eye  view.     An  investigation  aims  to  get  at  the 


DEFINITION   OF   A   PUBLIC   HEALTH  SURVEY  3 

facts  in  a  given  situation.  This  means  that  every  device, 
such  as  the  trained  mind,  the  trained  eye,  the  use  of  labora- 
tory facihties,  and  the  abihty  to  study  past  data,  must  be 
utihzed.  A  health  survey  is  therefore  an  investigation 
conducted  by  a  trained  corps  of  workers,  in  order  to  deter- 
mine the  exact  status  of  those  conditions  that  may  affect 
the  health  of  a  community  directly  or  indirectly.  This 
means  the  use  of  laboratory  facilities,  the  analysis  of  vital 
statistics  and  other  community  statistics,  inspections  of 
those  things  which  may  affect  the  public  health,  and  ,the 
obtaining  of  information  through  interviews  with  recog- 
nized officials  or  experts  in  a  community.  A  public  health 
survey  is  really  a  health  inventory  or  a  health  accounting. 
By  means  of  the  survey,  the  community  is  able  to  learn 
exactly  what  its  condition  is  in  regard  to  health.  It  may 
show  that  the  water-supply  and  sewage-disposal  facilities 
are  good  and  that  the  milk-supply  and  hospital  facilities 
are  poor.  It  may  serve  to  call  the  attention  of  the  people 
to  activities  which  should  be  started,  or  to  changes  which 
should  be  made  in  the  existing  system  of  public  health 
protection.  The  public  health  survey  attempts  to  ascer- 
tain the  debit  and  credit  sides  of  the  public  health  protec- 
tion which  a  community  offers. 

The  survey  may  be  compared  to  a  complete  and  thorough 
medical  examination  of  an  individual  by  a  physician.  In 
such  an  examination,  the  heart,  lungs,  urine  and  blood  are 
tested,  the  vision  and  sense  of  hearing  may  also  be  examined, 
and  the  height  and  weight,  and  other  measurements  of  the 
body  are  recorded.  The  individual's  hygienic  habits  and 
the  nature  of  his  occupation  are  studied,  and  recommenda- 
tions are  made  for  a  more  hygienic  life.  In  this  way,  the 
incipient  dangers  to  good  health  are  recognized  before  they 
become  serious.  If  the  individual  heeds  the  advice  which 
the  experienced  physician  gives,  he  may  enjoy  good  health 
and  a  prolonged  life.     The  Life  Extension  Institute  has 


4        INFORMATION   ABOUT   PUBLIC   HEALTH   SURVEYS 

done  a  great  deal  to  awaken  the  people,  not  only  to  the 
need  of  these  examinations,  but  to  the  necessity  of  having 
them  periodically.  So  it  must  eventually  be  with  every 
progressive  city  in  the  country.  Not  only  will  it  be  the 
practice  for  every  community  to  have  a  health  survey,  but 
it  will  become  customary  for  communities  to  be  re-surveyed 
periodically,  perhaps  once  in  every  five  or  ten  years.  This 
will  be  necessary  not  only  to  ascertain  the  true  status  of 
conditions,  but  also  to  stimulate  the  interest  of  the  people 
in  public  health  and  sanitation,  and  to  determine  along 
what  lines  the  public  funds  for  health  protection  can  be 
most  profitably  spent. 

The  public  health  survey  may  also  be  compared  to  the 
stock  inventory,  which  is  employed  by  every  business 
organization  engaged  in  the  manufacture,  sale  or  distribu- 
tion of  material  commodities.  Once  every  year,  and  some- 
times oftener,  such  organizations  take  stock,  and  deter- 
mine exactly  what  materials  are  on  hand,  and  the  quantity 
of  each  that  is  available.  By  means  of  this  inventory,  it 
is  also  possible  to  determine  the  amount  and  character  of 
the  goods  required  to  bring  the  supply  of  materials  to  the 
desired  degree.  Similarly,  the  public  health  survey  may 
be  compared  to  the  regular  business  accounting  which  takes 
place  periodically  in  every  progressive  organization.  Once 
every  year,  or,  in  some  cases,  less  frequently,  the  accounts 
are  examined  by  an  expert,  their  accuracy  determined,  and 
recommendations  made  for  an  improved  system,  if  this 
seems  necessary.  The  public  health  survey  aims  at  noth- 
ing more  and  nothing  less;  its  object  is  to  make  an  inven- 
tory of  conditions  affecting  the  public  health,  to  study 
them  with  the  eye  of  an  expert,  and  to  make  recommenda- 
tions, wherever  necessary,  for  an  improved  and  more  effi- 
cient system  of  public  health  protection. 

Qualifications  of  the  Surveyor.  —  Not  only  is  there  a 
lack  of  definite,  standardized  plans  of  procedure,  but  no 


QUALIFICATIONS  OF  THE  SURVEYOR  5 

attempt  has  been  made  to  specify  what  quahfications  a 
health  surveyor  should  have.  Should  he  be  a  physician, 
an  engineer,  a  social  worker,  a  political  economist,  or  a 
laboratorian?  What  should  have  been  his  training?  What 
mental  and  physical  characteristics  must  he  have  to  make 
a  successful  surveyor?  Since  health  surveys  have  been 
undertaken  without  knowledge  of  what  a  health  survey 
should  include,  or  what  the  qualifications  of  a  surveyor 
should  be,  and  without  definite  knowledge  of  any  good 
method  of  procedure,  there  is  little  wonder  that  surveys 
have  been  conducted  on  such  widely  different  plans.  It 
seems  to  the  author  that  a  public  health  survey  is  one  of 
the  broadest  pieces  of  municipal  work,  and  that,  since  it 
touches  the  community  in  so  many  different  phases,  the 
training  of  the  surveyor  must  be  correspondingly  broad. 
The  individual  should  have,  as  a  basis,  a  broad  and 
thorough  training  in  public  health  work.  One  who  does 
not  have  this  essential  technical  training  cannot  possibly 
hope  to  conduct  thorough  and  scientific  public  health  sur- 
veys. He  must  know  enough  about  municipal  engineering 
to  be  able  to  converse  with  and  understand  the  city  engi- 
neers. He  must  be  well  versed  in  the  purification  of  water 
and  sewage,  in  the  use  of  water  and  sewerage  systems,  and 
in  the  collection  and  disposal  of  refuse.  He  must  know 
enough  about  medicine  to  be  able  to  converse  with  phy- 
sicians on  the  prevalence  of  disease,  on  community  methods 
for  controlling  disease,  hospitalization,  dispensary  work,  and 
nursing.  The  surveyor  must  also  be  informed  regarding 
the  various  existing  forms  of  municipal  government.  It  is 
desirable  that  he  be  an  affable  individual,  with  a  pleasant, 
yet  forceful  manner  —  one  who  can  command  respect. 
Tact  is  one  of  the  essential  requisites  of  public  health  sur- 
vey work.  The  individual  who  cannot  win  the  confidence 
of  the  community,  and  find  some  way  to  overcome  the 
obstacles  that  constantly  arise,  is  certain  to  fail. 


6   INFORMATION  ABOUT  PUBLIC  HEALTH  SURVEYS 

The  Community  must  be  Interested  in  the  Survey.  — 
Politicians  of  all  kinds  must  be  met  and  won.  There  will 
be  department  heads  whose  work  will  be  under  investiga- 
tion, who  will  not  feel  kindly  disposed  toward  the  surveyor. 
Yet  it  is  imperative  that  cooperation  and  good-will  from 
these  sources  be  obtained.  There  will  be  the  individual 
who  is  happy  with  his  own  lot  in  life  and  has  concluded 
that  all  work  for  human  betterment  is  wasted  energy.  He 
*'has  no  use  "  for  "uphft  "  work;  yet  his  interest  and  co- 
operation must  also  be  obtained.  There  will  be  professional 
men  and  business  men,  who  are  really  interested  in  the 
proposed  survey,  but  who  are  too  busy  with  their  personal 
affairs  to  give  very  much  time  and  encouragement  to  the 
work.  Yet  every  effort  should  be  made  to  enlist  their 
active  as  well  as  their  moral  support,  in  order  to  show  that 
the  undertaking  is  a  community  effort,  supported  by  sound 
minds  that  are  interested  in  the  welfare  of  the  city.  There 
will  be  many  others,  both  male  and  female,  who  will  be 
only  too  glad  to  serve.  Some  will  be  faddists  and  over- 
enthusiastic.  Almost  all  will  require  direction.  All  of 
these  influences  must  be  maintained  at  the  proper  pitch  of 
enthusiasm  during  the  entire  period  of  the  survey.  There 
will  bejocal  jealousies,  local  animosities,  local  customs  and 
habits.  It  is  important  that  the  surveyor  should  acquaint 
himself  with  these  things  in  some  unobtrusive  way,  so  that 
he  may  avoid  injuring  certain  community  sore  spots.  The 
surveyor  should  become  acquainted  with  something  of  the 
history  and  peculiarities  of  the  community  as  soon  as 
possible. 

It  will  be  seen,  then,  that  the  surveyor  must  be  a  good 
organizer,  one  who  can,  if  necessary,  bring  together  the 
most  diverse  influences,  and  one  who  can  keep  all  interested 
and  satisfied.  To  this  end  it  is  also  desirable  that  he  be  a 
man  of  good  appearance  and  clean  personal  habits,  and  a 
clear  and  convincing  public  speaker.     In  addition,  he  should 


DATA  SHOULD  BE  ACCURATELY  INTERPRETED    7 

have  a  keen,  analj^tical  mind,  should  be  a  sharp  and  quick 
observer  and  should  have  good  judgment.  He  must  have 
his  technical  knowledge  at  his  fingers'  ends,  so  as  to  direct 
or  interpret  circumstances  without  loss  of  time.  Very 
often  he  will  be  required  to  do  laboratory  work,  and  should 
therefore  also  be  trained  and  experienced  in  this  direction, 
in  order  to  perform  his  work  efficiently.  This  training  is 
equally  important  in  interpreting  the  results  of  the  labora- 
tory findings  obtained  by  others.  Finally,  the  surveyor 
should  have  a  social  conscience.  He  should  be  able  to  see 
a  community  problem  in  its  entirety  and  foretell  how  it 
will  affect  those  who  may  be  concerned  in  it.  His  aim 
must  be  human  betterment;  yet  he  must  recommend  only 
those  plans  which  will  surely  be  of  benefit,  and  not  those 
which  are  open  to  serious  debate,  and  may  or  may  not 
prove  of  value.  He  must  distinguish  the  practical  from 
the  Utopian,  and  lend  every  influence  he  can  command  to 
the  adoption  of  the  former.  The  surveyor  should  not  be 
too  ambitious  in  the  program  he  recommends;  he  must 
remember  that  the  introduction  of  reforms  requires  a  great 
deal  of  time,  and  the  expenditure  of  large  sums  of  money. 
Very  often  it  is  even  necessary  to  educate  the  people  up 
to  that  point  where  they  will  see  the  need  and  value  of  a 
better  public  health  organization  and  increased  public 
health  activities.  As  far  as  possible,  the  surveyor  should 
employ  the  means  that  are  already  at  hand  in  order  to 
build  a  better  system.  It  is  easier  to  introduce  reforms  by 
following  this  method,  than  by  attempting  to  uproot  the 
old  system,  and  to  replace  it  by  one  that  is  entirely  new. 

Data  should  be  Accurately  Interpreted.  —  One  of  the 
essential  characteristics  of  a  surveyor  should  be  the  ability 
to  interpret  social  data,  vital  statistics,  laboratory  data 
and  other  information  correctly.  It  is  true,  only  too  often, 
that  the  community  worker  is  carried  away  completely  by 
the  effect  of  housing  on  health,  the  effect  of  exposed  garbage 


8        INFORMATION  ABOUT  PUBLIC   HEALTH  SURVEYS 

or  sewag;e,  or  the  relation  of  flies  to  disease.  These  things 
are  quite  obvious  and  readily  understood,  and  are  easily 
capable  of  arousing  puljlic  sentiment.  But  a  community, 
aroused  by  a  sentimental  surveyor  or  investigator  to  the 
necessity  of  reform  in  these  directions,  is  being  asked  to 
spend  money  and  energy  to  prevent  certain  minor  evils, 
while  there  may  be  others,  much  more  menacing  to  the  pub- 
lic health,  which  also  demand  immediate  remedy.  Such 
problems  as  a  pure  and  abundant  water-supply,  proper  and 
adequate  sewage-disposal,  a  safe  and  clean  milk-supply, 
the  prevention  of  contact  infection  in  the  schools  and  other 
places,  the  detection  and  care  of  tuberculous  cases,  proper 
hospitalization,  adequate  and  complete  vital  statistics, 
laboratory  facilities  for  diagnosing  disease,  public  health 
education  —  these  are  but  a  few  of  the  urgent  public  health 
problems  that  arise  in  many  communities.  To  understand 
these  correctly,  to  make  recommendations  that  will  be  sane 
and  worth  while,  requires  a  clear,  technical  knowledge  of 
these  subjects,  and  an  understanding  of  the  human  forces 
that  will  favor  or  hinder  the  work,  and  not  a  mere  senti- 
mental emotionalism  that  leads  nowhere.  Public  health 
progress  will  come  more  easily  and  be  more  permanent 
when  recommendations  are  based  on  facts,  on  scientific 
data,  accurately  interpreted,  than  when  they  are  based  on 
sentiment. 

Public  Health  Surveys  may  be  Private  or  Official.  —  A 
pubhc  health  survey  may  be  conducted  in  any  one  of  three 
ways.  The  investigator  may  enter  the  community  as  a 
private  individual,  without  official  power  or  standing,  and 
conduct  the  survey  alone,  except  for  the  merest  perfunc- 
tory cooperation  he  may  obtain  from  the  local  officials  and 
residents.  He  may  also  act  as  the  appointed  expert  of  a 
civic  body,  such  as  the  board  of  health,  or  chamber  of  com- 
merce, or  the  mayor  and  common  council.  Although  the 
individual  is  clothed  with  power  in  this  case,  he  may  con- 


OFFICIAL  SURVEYS  PROPERLY  ORGANIZED  9 

duct  the  work  without  much  or  any  pubHcity  or  coopera- 
tion. In  the  third  case,  the  investigator  is  employed,  as 
in  the  second  case,  by  some  civic  body;  but  the  community 
is  thoroughly  organized  and  prepared  for  the  survey,  there 
is  much  publicity  and  talk  about  it,  and  cooperation  may 
be  forthcoming  from  many  directions. 

Official  Surveys  Properly  Organized  and  Conducted 
with  Much  Publicity  are  Best.  —  The  last  method  is  un- 
doubtedly the  best,  for  it  enables  the  investigator  to  obtain 
the  facts  more  readily  and  to  work  more  thoroughly.  The 
investigator,  in  such  a  case,  is  regarded  as  the  servant  and 
friend  of  the  community.  In  this  capacity,  he  is  able  to 
penetrate  more  deeply  into  the  existing  conditions  than  if 
he  were  simply  regarded  as  an  outsider  without  any  right 
to  pry  into  the  affairs  of  the  city  or  into  those  of  private 
individuals.  One  of  the  essential  benefits  derived  from 
publicity  is  that  the  people  are  keyed  up  to  the  survey. 
They  are  in  a  proper  frame  of  mind  for  receiving  instruc- 
tion in  the  value  of  hygienic  living  and  sanitary  surround- 
ings. This  opportunity  for  effective  public  health  educa- 
tion should  not  be  missed;  the  proper  and  thorough  edu- 
cation of  the  people  may  not  only  lead  to  individual  benefit, 
but  should  also  be  one  of  the  potent  factors  in  aiding  the 
introduction  of  sanitary  reforms  or  improvements  after  the 
survey  is  over.  During  the  period  of  the  survey,  the  people 
will  become  interested  in  their  milk-supply,  their  water- 
supply,  the  food  markets  and  other  things  that  directly 
affect  their  daily  lives.  The  cover  will  be  tightly  clapped 
on  the  garbage-can,  empty  tin  cans  will  be  removed,  and  a 
general  clean-up  of  the  premises  will  take  place  in  many 
cases  before  the  inspections  begin.  While  some  of  these 
activities  are  of  doubtful  sanitary  value,  they  are  all  of 
great  psychological  value.  When  a  favorable  mental  atti- 
tude is  created  it  is  much  easier  to  bring  home  some  really 
valuable  lessons  in  hygiene  and  sanitation. 


CHAPTER   II 

ORGANIZING   A   COMMUNITY   FOR   A   PUBLIC 

HEALTH    SURVEY 

Satisfactory  Organization  Essential  for  Success.  —  The 
organization  of  the  community  for  the  survey  is  one  of  the 
most  important  parts  of  the  work.  On  the  completeness, 
character  and  make-up  of  the  organization  and  the  coopera- 
tion of  the  indivichials  who  compose  it,  depend  not  only 
the  thoroughness  with  which  the  survey  can  be  made,  but 
also  the  effectiveness  of  any  improvements  that  may  be 
introduced  later,  as  a  result  of  the  investigation.  The 
organization  should,  of  course,  be  formed  by  the  local  body 
in  charge  of  the  survey,  and  should  consist  of  a  central 
committee  and  several  sub-committees.  The  central  com- 
mittee should  be  as  representative  as  possible,  and  have, 
as  members,  men  and  women  from  all  walks  of  life,  repre- 
senting every  community  interest.  These  persons  should 
be  individuals  who  are  well  known  in  the  city,  and  who 
command  respect  and  attention. 

The  interests  represented  should,  at  least,  include  the 
following:  the  city  administration,  the  health  department, 
the  anti-tuberculosis  association,  the  visiting  nurses'  asso- 
ciation, the  schools,  the  chamber  of  commerce,  the  business 
men's  clubs,  the  women's  clubs,  the  Y.  M.  C.  A.,  the 
Y.  W.  C.  A.,  the  labor  organizations,  the  clergy,  the  medi- 
cal profession,  the  press,  the  charities  and  any  other  specific 
interest  that  may  be  peculiar  to  the  community.  During 
the  period  of  the  war,  it  was  also  customary  to  invite  rep- 
resentatives of  the  Red  Cross  and  the  local  Council  of 
National  Defense.     In  inviting  the  clergy,  care  should  bo 

10 


SATISFACTORY   ORGANIZATION  ESSENTIAL  11 

taken  to  include  all  the  important  sects  that  are  represented 
in  the  community.  The  representative  of  the  health  de- 
partment should  preferably  be  the  health  officer  himself, 
since  he  is  to  bear  the  brunt  of  the  criticism  if  his  depart- 
ment is  found  wanting.  It  would  be  desirable  too  to  have, 
on  the  committee,  representatives  of  the  engineering  and 
the  legal  professions,  and  any  other  important  and  active 
civic  leaders  who  have  not  been  included  in  the  plan  which 
has  been  outlined. 

Invitations  to  become  members  of  the  central  committee 
should  be  sent  out  by  a  temporary  chairman,  appointed  to 
the  position.  If  possible  the  meetings  of  the  members  of 
the  central  committee  should  take  the  form  of  luncheons. 
At  these  meetings  a  permanent  organization  may  be  per- 
fected, and  a  permanent  chairman  elected.  The  purpose 
and  plan  of  the  survey  should  be  made  known  by  some- 
body who  is  in  a  position  to  explain  it,  and,  if  possible, 
each  member  of  the  committee  should  be  furnished,  by  the 
surveyor,  with  a  skeleton  outline  of  the  things  the  survey 
hopes  to  consider. 

Various  sub-committees  should  also  be  appointed. 
These  need  not  be  numerous,  but  should  include  committees 
on  housing,  on  transportation  and  on  publicity.  There 
may  possibly  be  added  a  committee  on  budgets.  The 
housing  committee  is  necessary  only  when  the  community 
is  planning  to  conduct  the  housing  survey  by  the  aid  of 
voluntary  workers.  Where  this  part  of  the  work  is  done 
by  a  trained  corps  of  workers  employed  especially  for  the 
purpose,  or  by  local  city  inspectors,  a  housing  committee 
is  not  necessary.  The  transportation  committee  is  neces- 
sary to  furnish  means  of  conveyance  to  the  surveyor  and 
his  assistants,  in  order  to  save  time  and  energy  for  the 
survey.  The  publicity  committee  is  necessary  to  keep  the 
survey  before  the  minds  of  the  people,  and  to  maintain  the 
interest  of  the  community  at  a  high  pitch.     Sometimes  there 


12  ORGANIZING   A  COMMUNITY 

is  particular  interest  on  the  part  of  the  citizens  in  learning 
about  the  distribution  of  the  public  funds.  Where  this 
sentiment  is  particularly  strong  it  is  desirable  to  have  a 
budget  committee  to  aid  the  surveyor  in  studying  the 
appropriations  and  expenditures  of  the  various  city  depart- 
ments. Having  perfected  the  organization,  the  central 
committee  and  the  various  sub-committees  are  now  ready 
for  the  arrival  of  the  expert. 

Surveyor  should  Outline  Plan.  —  With  the  arrival  of  the 
expert,  the  work  of  organizing  the  survey  must  be  brought 
to  a  close.  In  order  that  the  committee  may  learn,  directly 
from  the  investigator,  the  nature,  purpose  and  scope  of  a 
health  survey,  a  meeting  should  be  called,  at  which  every 
member  of  the  central  committee  should  be  present.  At 
this  meeting  the  expert  should  outline  the  work,  tell  what 
he  hopes  to  do,  and  emphasize  the  need  of  cooperation  on 
the  part  of  the  committee.  It  is  important  that  the  expert 
should  make  a  favorable  impression  at  this  meeting,  in 
order  to  win  the  confidence  of  the  committee.  It  is  also 
very  desirable  to  make  specific  requests  for  cooperation  at 
this  meeting.  Such  things  as  transportation  facilities, 
laboratory  facilities,  the  organization  for  the  housing  sur- 
vey, publicity  and  education  and  office  facilities  should  be 
mentioned.  Definite  action  should  be  taken  at  this  time 
by  the  committee,  to  provide  the  things  required,  or  to 
insure  that  they  will  be  furnished  when  necessary. 

Arrangements  for  Publicity.  —  The  i)u])licity  work,  in  a 
large  city,  will  be  placed  in  charge  of  a  committee,  and, 
except  for  furnishing  information  relative  to  the  progress 
of  the  survey,  the  expert  will  have  very  little  cause  to 
worry  over  this  portion  of  the  work.  In  a  small  city,  the 
task  of  preparing  articles  for  the  daily  papers  will  fall  on 
him,  and  this  must  be  done  after  the  day's  work  is  over. 

Publicity  During  the  Survey.  —  This  can  l^o  provided  in 
many  ways;    l)ut  perhaps  the  best  medium  is  the  daily 


PUBLICITY  DURING  THE  SURVEY  13 

newspaper.  Almost  every  adult  reads  some  newspaper 
every  day.  Short  and  appealing  stories,  appearing  every 
day  during  the  period  of  the  survey,  and  at  less  frequent 
intervals  before  the  survey  begins,  should  outline  the  nature 
of  the  work,  the  value  of  the  undertaking  to  the  com- 
munity, the  benefit  that  the  individual  may  derive,  and  the 
necessity  for  general  cooperation. 

Some  description  of  the  conditions  found  at  the  begin- 
ning of  the  survey  may  be  given,  although  this  is  very 
difficult  to  manage  without  hampering  the  survey.  The 
people  are,  of  course,  interested  in  the  findings  of  the  in- 
vestigator. If  the  investigation  shows  the  existence  of 
good  conditions,  such  as  a  safe  water-supply  or  adequate 
sewerage  and  proper  sewage-disposal,  it  is  desirable  to  make 
these  facts  public  during  the  period  of  the  survey.  Should 
the  conditions  be  generally  good,  additional  points  of 
interest  may  also  be  advantageously  made  public. 

The  vexing  problem  is  to  determine  what  to  make  public 
and  how  much.  It  would  not  be  at  all  wise  to  give  to  the 
press  the  daily  findings,  even  if  they  were  all  satisfactory. 
If  that  were  done,  the  interest  would  soon  die  out,  and  the 
necessary  cooperation  would  probably  not  be  forthcoming. 
Moreover,  it  is  certain  that  the  educational  value  of  the 
survey  would  be  distinctly  impaired.  On  the  other  hand, 
if  the  investigation  discloses  many  evil  conditions,  it  is 
again  unwise  to  publish  them  in  full.  Should  this  be  done 
many  interests  would  be  antagonized,  and,  instead  of  aid- 
ing the  survey,  they  would  oppose  it  in  a  determined  and 
effective  way.  This  would  immediately  result  in  closing 
the  doors  leading  to  much  otherwise  available  data,  and 
the  survey  would  suffer  in  direct  proportion  to  the  power 
and  extent  of  the  opposition. 

It  is,  nevertheless,  desirable,  in  order  to  arouse  interest, 
and  to  stimulate  wholesome  opposition,  to  give  to  the  pub- 
lic certain  facts  which  portray  unsatisfactory  conditions. 


14  ORGANIZING  A  COMMUNITY 

It  will  pr(>l:>ably  be  best  to  do  this  mainly  through  the  pub- 
licity committee  of  the  central  committee.  The  surveyor 
should,  however,  always  be  certain  of  his  facts.  Should 
someone  be  able  to  disprove  what  he  says,  or  demonstrate 
some  serious  flaw  in  his  findings,  the  people  would  imme- 
diately lose  confidence  in  the  rest  of  the  survey  and  its 
value  would  therefore  be  lost.  It  is  difficult  to  say  which 
facts  should  be  made  public  and  which  should  not  be  dis- 
closed during  the  progress  of  the  survey.  If  such  a  thing 
as  the  milk-supply,  which  affects  the  health  of  the  com- 
munity very  directly,  is  found  to  be  very  unsatisfactory,  it 
would  be  wisest  to  give  the  information  to  the  public 
without  much  delay.  If  the  findings  are  not  very  serious, 
but  the  field  in  which  the  data  are  obtained  is  one  that  is 
important,  and  affects  the  livelihood  and  interests  of  many 
people,  it  would  be  best  to  postpone  the  disclosure  until  the 
final  report  is  made.  It  may,  however,  be  indicated  in  the 
preliminary  report  if  this  is  thought  desirable. 

There  are  many  things,  however,  that  can  be  made  pub- 
lic immediately.  These  include  the  presence  of  the  com- 
mon drinking-cup  in  schools,  public  buildings  or  private 
places  of  assembly,  a  polluted  swimming-pool,  improper 
disposal  of  manure  and  garbage,  resulting  in  a  fly  nuisance, 
mosquito-breeding  places,  open  privies,  poor  methods  of 
cleaning  and  washing  dishes  and  glasses  in  food-stores  and 
at  soda-fountains,  and  hosts  of  other  things  that  have  a 
direct  bearing  on  the  public  health,  which  can  be  remedied 
without  great  cost  or  expenditure  of  time,  and  which  fre- 
quently depend  on  the  individual  for  correction.  On  the 
other  hand,  it  would  be  unwise  to  condemn  the  public 
water-supply  or  to  expose  certain  industrial  conditions, 
without  first  attempting  to  have  the  existing  conditions 
remedied  through  the  cooperative  effort  of  those  who  are 
responsible.  There  are  times  when  it  is  necessary  to 
expose  conditions  in  order  to  obtain  improvements.     In 


PUBLICITY  DURING  THE  SURVEY  15 

such  cases  the  investigator  should  fight  hard  and  openly 
and  be  a  champion  of  the  truth.  On  the  other  hand  evils 
frequently  exist  because  of  ignorance  or  lack  of  interest, 
and  can  often  be  remedied  by  united  action  resulting  from 
enlightenment.  To  maintain  the  good- will  of  the  citizens 
without  injuring  their  interests,  succeeding,  at  the  same 
time,  in  instituting  the  desired  reforms,  is  highly  important. 
Such  reforms  are  lasting  and  mark  a  great  advance  in 
public  welfare. 

The  character  of  the  publicity  must  also  depend  on  the 
temper  of  the  community  in  which  the  survey  is  being  made. 
Some  communities  are  exceedingly  sensitive,  even  to  mild 
criticism,  and  it  is  very  difficult  to  give  any  adverse  opinions 
without  immediately  arousing  the  wrath  and  antipathy  of 
the  people.  The  author  had  an  experience  of  this  kind  in 
Enid,  Oklahoma,  where  an  unusually  inflated  local  pride 
and  a  tremendous  fear  of  being  improperly  represented  to 
people  in  other  parts  of  the  United  States,  made  it  par- 
ticularly difficult  to  carry  on  publicity  at  all.  This  was 
the  more  surprising  because  of  the  fact  that  the  health 
conditions  in  this  city  deserved  much  praise.  However, 
the  dread  of  even  the  sfightest  adverse  criticism  almost 
resulted  in  undermining  all  the  good  that  was  in  process 
of  being  accompUshed.  On  the  other  hand,  cities  hke 
Ardmore  and  Shawnee,  Oklahoma,  were  found  to  be  almost 
immune  to  adverse  criticis  n.  One  could  condemn  existing 
conditions  quite  openly  and  forcibly,  without  arousing  the 
community. 

The  author  has  found  that  one  of  the  best  ways  to  stimu- 
late communities  to  interest  and  action  in  a  public  health 
survey  is  to  criticize  the  production  and  handling  of  the 
milk-supply,  wherever  such  criticism  is  justifiable.  Every 
person  in  a  community  uses  milk  or  milk  products;  and 
many  communities  have  doubtless  experienced  epidemics 
of  diphtheria,  typhoid  fever  or  some  other  disease,  which 


16  ORGANIZING  A  COMMUNITY 

have  been  traced,  more  or  less  definitely,  to  the  niilk- 
suppl3\  It  is  therefore  easy  to  see  that  the  people  will  be 
greatly  interested  in  the  milk-supply,  and  will  be  readily 
stirred  to  action  to  improve  the  conditions  under  which 
milk  is  produced"  and  handled.  The  method  pursued  has 
been  to  inspect  and  score  the  farms  where  the  milk  is  being 
produced,  and  to  analyze  the  milk  after  it  arrives  in  the 
city.  The  results  obtained  are  tabulated  and  published 
in  the  newspapers,  together  with  a  statement  explaining 
the  results.  The  names  of  the  dealers  are  not  made  public 
at  this  time,  but  are  disclosed  in  the  final  report. 

In  McAlester,  Oklahoma,  the  conditions  at  one  dairy 
were  so  vile,  that  the  author  persuaded  a  group  of  leading 
citizens  to  make  an  inspection  of  the  dairy  under  his  direc- 
tion. As  a  result,  immediate  action  was  taken  by  these 
citizens  to  cause  the  milk  from  this  dairy  to  be  excluded 
from  the  regular  communal  supply. 

McAlester  was  an  unusual  city  in  many  ways.  It  had  a 
virile,  active  and  public-spirited  citizenry,  who  were  not 
afraid  to  learn  their  defects.  In  fact  they  were  anxious  to 
know  them,  and  to  know  the  methods  by  which  they  could 
be  remedied.  The  editor  of  the  local  newspaper  was  a 
particularly  forward-looking  man.  He  published  frequent 
editorials  on  the  work  of  the  survey,  and  even  wrote  stories 
to  instruct  the  people  in  the  nature  and  value  of  the  inves- 
tigation, and  to  allay  the  fear  that  the  survey  would  in- 
quire into  their  private  lives  and  possessions.  Daily  articles 
by  the  author  were  given  a  prominent  \ihicQ  in  the  paper. 
It  was  even  possible  to  organize  the  women  to  obtain  cer- 
tain information  relating  to  housing,  l)y  means  of  a  house-to- 
house  canvass  conducted  during  the  heat  of  August,  although 
the  thermometer  in  the  Southwest  at  that  time  of  the  year 
usually  registers  above  90°  F.  The  author  conducted  the 
survey  at  a  time  when  the  pul)lic  water-supply  was  regarded 
with  suspicion,  because  of  tastes  and  odors  due  to  algae, 


PUBLICITY   DURING  THE   SURVEY  17 

and  because  of  an  inaccurate  bacteriological  examination. 
As  a  result  of  a  personal  inspection  of  the  source  of  water- 
supply,  and  of  analyses  made  on  the  spot,  he  was  able  to 
aid  the  local  authorities  in  restoring  public  confidence  in  the 
municipal  water-supply.  Any  surveyor  may  find  himself 
confronted  with  a  specific  problem  that  is  perplexing  the 
people  in  the  city  where  the  survey  is  being  made.  In  such 
a  case,  he  must  be  ready  to  take  a  definite  stand,  based  on 
a  thorough  personal  investigation  of  the  problem. 

Sometimes  the  surveyor  will  find  that  the  lake  or  reser- 
voir from  which  the  people  obtain  their  water-supply  is 
used,  with  official  sanction,  for  boating  and  fishing,  and  that 
picnics  are  held  on  its  shores.  This  is  always  a  menace 
to  the  safety  of  the  supply,  and  it  may  be  desirable  to 
expose  the  existing  conditions  immediately,  in  order  to 
overcome  the  evils.  Such  a  situation  was  met  by  the 
author  in  Ardmore,  Oklahoma. 

In  some  cases,  two  cities  within  the  same  state  may  be 
keen  and  bitter  rivals  for  commercial  supremacy  and 
leadership.  In  such  a  case  particular  care  should  be  exer- 
cised, in  making  public  the  plans  of  either  city.  It  is 
desirable  that  all  important  contributions  to  the  public 
press,  dealing  with  the  survey  or  its  findings,  should  first 
be  submitted  to  the  central  committee,  or  to  the  committee 
on  publicity,  chosen  from  the  central  committee.  It  is 
desirable,  in  fact,  that  the  central  committee  assume  the 
responsibility  for  the  articles  that  appear  in  the  news- 
papers. In  this  way,  the  surveyor  will  be  freed  from 
unpleasant  reactions,  which  would  be  sure  to  hinder  the 
progress  of  the  survey  and  of  all  later  attempts  to  bring 
about  an  improvement  in  existing  conditions.  He  will  also 
be  freed  from  the  charge  of  being  a  sensationalist  •  and 
notoriety  seeker.  He  may,  of  course,  have  his  findings 
questioned,  as  is  just  and  proper;  and  in  such  cases  he 
should  be  ready  to  defend  his  statements. 


18  ORGANIZING  A  COMMUNITY 

Some  communities  are  particularly  mindful  of  the  effect 
that  adverse  criticism  may  have  on  the  growth  of  business 
and  industrial  activity.  It  is  absolutely  necessary,  in  every 
ease,  to  work  with  the  interests  involved  and  not  against 
them.  Usually  they  can  be  made  to  see  the  real  and  per- 
manent benefits  that  will  be  derived  from  the  recognition, 
and  the  subsequent  improvement,  of  undesirable  conditions. 
It  is  because  of  these  ever-present  psychological  factors 
that  the  publicity  must  be  carefully  conducted,  accurate 
in  its  statements,  and  sponsored  by  responsible  members 
of  the  community.  In  order  to  avoid  misquotation,  it  is 
desirable,  where  time  permits,  to  submit  the  story  for 
publication  in  writing.  If  this  is  not  possible,  care  must 
be  taken  to  make  the  reporter  understand  the  subject 
thoroughly,  and  see  that  he  has  obtained  a  correct  version 
of  the  information  that  has  been  imparted. 

The  Surveyor  should  Antagonize  as  Few  Persons  as 
Possible.  —  Except  under  unusual  circumstances,  it  is 
undesirable  to  condemn  city  officials  or  private  individuals, 
either  in  public  or  through  the  press.  This  only  serves  to 
antagonize  the  individual,  who  will  become  sullen  and  stub- 
born, and  will  probably  find  many  to  sympathize  with  him 
and  even  aid  him  in  his  fight  for  revenge.  The  investigator 
should  not  beheve,  therefore,  that  he  will  have  his  own 
way  completely.  If  the  individual  attacked  is  a  public 
official,  other  members  of  the  administration  are  likely  to 
champion  his  cause.  In  such  a  case,  the  necessary  infor- 
mation, which  should  come  through  official  channels,  will 
be  withheld,  or  the  avenues  of  approach  will  be  blocked  by 
numerous  and  frequently  insurmountable  obstructions.  In 
short,  throughout  the  entire  period  of  the  survey,  the  in- 
vestigator must  antagonize  as  few  persons  as  possible.  In 
fact  he  must  win  cooperation  and  good-will  everywhere. 
He  must  realize  that  his  prime  duty  is  to  obtain  as  many 
facts  as  possible;  and  to  achieve  this  supreme  goal,  it  may 
be  necessary  to  postpone,  for  a  time,  the  publication  or 


COMMUNITY   MUST   BE   INSTRUCTED  19 

disclosure  of  facts  which  will  materially  affect  the  thorough- 
ness and  value  of  the  survey. 

Community  must  be  Instructed  in  Nature  and  Purpose 
of  Survey.  —  Another  important  duty  of  the  investigator 
is  to  place  the  purpose  and  plan  of  the  survey  before  the 
business  men  and  the  public-spirited  citizens.  To  do  this, 
it  will  be  necessary  to  appear  at  the  meetings  of  the  im- 
portant clubs  and  to  inform  these  men  about  the  survey. 
Since  one  or  several  members  of  each  club  will  also  be  mem- 
bers of  the  central  committee,  it  is  usually  a  simple  matter 
to  obtain  this  privilege.  If  a  club  can  cooperate  in  any 
way,  either  immediately  or  at  some  future  time,  it  is  wise 
to  say  so,  and  to  outline  the  method  in  which  the  aid 
should  be  given.  The  hioral  support  of  such  organizations 
should  always  be  obtained,  if  possible. 

Not  only  is  it  important  to  appear  before  the  business 
men's  club,  but  it  is  equally  necessary  to  acquaint  the 
physicians  with  the  plans  of  the  survey,  and  to  receive 
their  endorsement  and  support.  This  can  best  be  done 
by  outlining  the  scope  and  purpose  of  the  work  at  a  meet- 
ing of  the  county  or  the  local  medical  society,  'choosing, 
for  this  purpose,  the  organization  which  actually  includes 
most  of  the  local  physicians.  Since  the  medical  profes- 
sion is  also  represented  on  the  central  committee,  it  will  be 
possible,  without  much  difficulty,  to  obtain  this  privilege  too. 
Since  the  physicians  may  be  called  upon  for  specific  aid,  either 
for  statistics  or  medical  service,  it  is  obviously  necessary 
that  their  confidence,  cooperation  and  support  be  gained. 

In  order  to  bring  the  news  and  purpose  of  the  survey  to 
those  who  are  industrially  employed,  it  is  desirable  to 
arrange  meetings  at  which  they  may  become  informed. 
Such  meetings  can  be  arranged  either  during  the  lunch 
period  or  at  night.  The  surveyor  should  not  neglect  this 
opportunity  to  bring  home  several  simple  yet  important 
lessons  in  public  health  and  hygiene.     After  all,  the  pubHc 


20  ORGANIZING  A  COMxMUNITY 

health  survey  is  a  large  imdcrtakin<2;  to  make  health  con- 
ditions better;  and,  if  these  people  who  need  good  health 
conditions  most  can  be  shown  how  to  improve  their  living 
conditions,  the  purpose  of  the  survey  will  be  effectively 
served.  Not  only  is  it  possible  to  spread  the  gospel  of 
healthy  living  at  such  meetings,  but  the  cooperation  of  the 
people  may  be  obtained.  By  outlining  the  things  that  are 
to  be  done,  and  specifjdng  what  may  be  expected  under 
satisfactory  conditions,  much  actual  improvement  may  be 
accomplished.  It  is  always  important,  however,  that  the 
person  charged  with  arranging  for  the  meeting  should 
arouse  enough  interest  and  curiosity  to  secure  a  large 
attendance. 

The  message  to  the  people  can  also  be  conveyed  through 
the  churches.  If  it  is  possible  —  and  it  usually  is  —  a 
Sunday  should  be  designated  as  ''Health  Sunday."  On 
this  day,  which  should  come  during  the  period  devoted  to 
the  public  health  survey,  this  undertaking  should  be  dis- 
cussed in  every  pulpit.  It  is  only  necessary  to  devote 
about  five  minutes  to  the  subject.  A  physician  or  a  civic 
leader,  preferably  a  member  of  the  congregation,  may  place 
the  subject  before  the  people,  emphasizing  their  rchition- 
ship  to  the  survey,  and  outlining  its  plan  and  purpose. 

Other  means  whereby  the  survey  can  be  brought  to  the 
attention  of  the  people  are  the  moving  picture  theaters, 
the  schools,  and  the  various  meetings  which  are  scheduled 
to  take  place  din-ing  the  period  of  the  survey. 

Such  a  plan  as  is  here  outlined  would  take  up  much,  if 
not  all,  of  the  spare  time  of  the  investigator.  Too  much 
should  not  be  attempted,  and,  if  possible,  the  work  should 
be  spread  throughout  the  entire  period  of  the  survey. 
Wherever  possible,  one  or  two  assistants  should  aid  in  this 
part  of  the  work.  There  can  be  no  doubt  that  this  propa- 
ganda is  important,  and  that  the  success  of  this  branch  of 
the  work  will  also  mean  the  success  of  the  survey. 


ARRANGEMENTS   FOR  LABORATORY  WORK  21 

Arrangements  for  Transportation.  —  With  reference  to 
transportation  facilities,  either  one  of  two  arrangements  is 
usually  made.  Either  the  expert  is  furnished  an  auto- 
mobile, or  else  he  is  required  to  depend  on  the  use  of  private 
automobiles  donated  for  a  day  by  various  citizens  in  the 
community.  Sometimes  a  municipal  automobile  is  placed 
at  the  service  of  the  investigator  either  for  the  duration  of 
the  survey  or  for  certain  specified  periods.  The  first 
method,  whereby  the  individual  has  an  automobile  at  his 
service  all  the  time,  is,  without  question,  the  better  arrange- 
ment. The  other  possibility  leads  to  much  loss  of  time, 
and,  usually,  to  considerable  annoyance.  It  is,  of  course, 
desirable  that  the  expert  should  be  able  to  drive  the  ma- 
chine himself.  Otherwise  he  must  rely,  for  this  service 
also,  on  the  kindness  and  convenience  of  residents  in  the 
city. 

Arrangements  for  Laboratory  Work.  —  One  of  the  first 
things  to  be  determined  is  whether  laboratory  facilities 
for  chemical  and  bacteriological  analyses  of  water  and 
milk  are  available  in  the  city;  and,  if  they  are,  whether 
they  will  be  placed  at  the  disposal  of  the  surveyor.  Fre- 
quently these  facilities  are  found  in  the  laboratories  of  the 
local  health  department.  If  the  survey  is  in  the  state 
capital,  the  state  health  department  laboratories  may  be 
used.  Sometimes  it  is  necessary  to  make  use  of  a  private 
physician's  laboratory,  or  the  laboratory  in  a  ho'spital,  in 
an  industrial  plant,  or  at  the  water  works.  Laboratory 
facilities  can  be  found,  nowadays,  in  almost  any  city. 
Through  the  influence  of  the  central  committee  or  some 
individual,  the  use  of  the  existing  facilities  can  usually  be 
arranged  for.  Unless  other  arrangements  can  be  made, 
the  surveyor  must  manage  to  do  his  own  work,  wash  the 
dirty  glassware,  prepare  and  sterilize  the  necessary  media 
and  other  materials,  and,  in  short,  do  almost  everything 
alone.     He  should  impose  on  his  benefactors  as  little  as 


22  ORGANIZING  A  COMMUNITY 

possible.  In  some  places  the  necessary  materials  for 
laboratory  work  will  not  be  available,  and  the  surveyor 
will  be  required  to  furnish  almost  all  of  them. 

Arrangements  for  the  Housing  Survey.  —  Some  arrange- 
ment should  also  be  made  at  the  first  meeting  for  organiz- 
ing the  housing  survey  and  getting  it  under  way.  At  the 
time  of  the  arrival  of  the  expert,  a  housing  committee, 
which  is  part  of  the  central  committee,  will  be  in  existence, 
if  the  preliminary  organization  for  the  survey  has  been 
satisfactory.  During  the  preliminary  preparations,  before 
the  arrival  of  the  expert,  the  housing  committee  should 
have  divided  up  the  city  into  wards  or  districts.  District 
chairmen  or  captains  should  have  been  appointed  for  each 
district,  and  each  district  further  divided  into  numerous 
precincts.  At  least  one  lieutenant  for  each  precinct  should 
be  appointed.  By  using  many  workers,  and  assigning 
only  a  small  territory  to  each,  the  entire  city  can  be  covered 
completely  in  a  short  time,  without  overtaxing  any  indi- 
vidual worker. 

Having  perfected  the  organization,  the  citizens  should 
await  the  arrival  of  the  expert,  for  directions  as  to  the 
method  of  collecting  the  data.  If  the  city  is  small,  the 
housing  committee  may  perhaps  meet  with  the  central 
committee  at  the  first  meeting  at  which  the  expert  is 
present.  The  expert  should  then  outline  clearly  the 
method  to  be  employed  in  collecting  the  data.  He  should 
explain  all  the  technical  terms  found  on  the  form-card  on 
which  the  information  is  to  be  recorded,  and  try  to  foresee 
some  of  the  problems  that  may  arise.  Advice  on  how  to 
overcome  these  obstacles  should  also  be  given.  After  the 
expert  is  through  talking  he  should  invite  discussion  and 
answer  all  questions. 

Arrangements  should  also  be  made  for  the  distribution 
and  collection  of  the  form-cards  used  in  the  work.  This 
is  best  done  through  the  housing  committee  and  the  cap- 


ARRANGEMENTS   FOR  THE   HOUSING   SURVEY       23 

tains.  The  committee  should  supply  the  captains  with 
the  necessary  cards,  and  these  in  turn  should  supply  their 
lieutenants.  When  the  cards  are  gathered  again,  the  lieu- 
tenants should  turn  them  in  to  the  captains,  who  will  pass 
them  on  to  the  housing  committee.  As  each  batch  of  cards 
is  turned  in,  the  corresponding  precinct  should  be  checked 
off  on  a  special  map  or  outline,  first  by  the  captain,  and 
later  by  the  housing  committee.  In  this  way,  definite 
information  as  to  the  amount  of  territory  that  has  been 
covered  can  easily  be  ascertained.  It  is  very  desirable 
that  an  office  or  a  part  thereof  should  be  assigned  to  the 
committee,  while  the  housing  survey  is  in  progress.  All 
the  cards  should  finally  be  turned  in  at  this  place. 

If  sections  occupied  by  colored  people  have  to  be  included 
in  the  housing  survey,  it  is  desirable  to  turn  this  work 
over  to  intelligent  colored  residents  or  to  colored  school- 
teachers. Not  only  will  thej^  be  able  to  obtain  more 
reliable  data,  but  it  is  also  likely  that  the  whites  will  be 
unwilling  to  work  in  the  colored  sections.  It  is  also  unwise 
to  send  young  women  into  sections  where  the  possibility 
of  harm  or  even  of  disagreeable  experience  is  present. 

The  organization  of  the  colored  workers  can  be  accom- 
plished at  the  same  time  as  that  of  the  whites,  if  there  is 
no  feeling  against  such  a  course.  Where  there  is,  it  may  be 
necessary  to  organize  the  colored  workers  separately.  In- 
telligent colored  volunteers  can  usually  be  obtained  by  the 
colored  ministers  or  the  colored  principals  in  the  public 
schools.  The  colored  workers  should  also  be  addressed  by 
the  surveyor;  and  the  information  imparted  to  the  whites 
should  be  repeated.  Great  care  should  be  taken  to  make 
the  directions  explicit  and  clear. 

It  is  also  important  to  make  perfectly  clear  that  the 
housing  inspectors  will  not  inspect  kitchens,  pantries, 
clothing-closets,  cellars  and  similar  private  places  in  the 
home.     Considerable    opposition    developed    against    the 


24  ORGANIZING   A   COMMUNITY 

housing  survey  in  ^IcAlester,  Oklahoma,  because  of  this 
fear  on  the  part  of  the  housewives.  It  was  necessary  to 
convince  the  women  by  repeated  articles  in  the  newspapers, 
and  also  l)y  addresses  to  groups  of  women,  that  such  an 
investigation  into  the  personal  habits  of  the  people  in  their 
homes  was  not  contemplated. 

Complaints  Resulting  from  Housing  Survey.  —  All  com- 
plaints which  may  come  to  the  attention  of  the  workers, 
during  the  housing  survey,  should  be  turned  over  to  the 
housing  committee.  Instead  of  being  allowed  to  take  up 
the  time  of  the  expert,  these  matters  should  be  investigated 
and,  if  necessary,  corrected  by  the  health  officer.  If  the 
problem  is  really  serious,  it  may  be  referred  to  the  expert. 
The  investigator  must  always  bear  in  mind  that  his  main 
purpose  is  to  get  the  facts  and  not  to  reform.  The  time 
is  usually  too  short  to  permit  the  latter.  Should  he  be 
able,  however,  to  improve  conditions  by  pointing  out  de- 
fects, and  by  suggesting  remedies,  he  should,  by  all  means, 
do  so,  for,  after  all,  one  of  the  main  purposes  of  the  survey 
is  to  bring  about  an  improvement  in  the  existing  conditions. 

Arranging  for  Housing  Study  in  Large  Cities.  —  In  a 
large  city,  instead  of  having  the  housing  workers  meet  with 
the  central  committee,  it  is  desirable  to  call  a  separate 
meeting  of  the  captains  and  lieutenants.  If  possible,  it  is 
desirable  that  a  luncheon  precede  the  meeting.  After  the 
luncheon,  the  meeting  should  be  opened  by  one  or  two  brief 
speeches  by  respected  members  of  the  community,  such 
as  a  representative  of  the  clergy,  or  the  president  of  the 
local  organization  fostering  the  survey,  or  some  city  official. 
Then  the  expert  should  ])e  called  upon  to  explain  in  detail 
the  nature  of  the  housing  survey  and  the  methods  to  be 
followed.  Not  only  is  it  important  to  explain  the  work 
carefully,  l)ut  it  is  also  important  to  arouse  the  enthusiasm 
of  the  volunteer  workers,  so  that  they  begin  the  campaign 
with  a  strong  desire  to  do  a  good  piece  of  work.     At  this 


STUDY  HOUSING  CONDITIONS   PERSONALLY         25 

meeting,  also,  discussion  should  be  invited,  in  order  that 
questions  may  be  asked  and  difficulties  cleared  up. 

Housing  Workers  should   Receive   Public  Approbation. 

—  It  should  be  remembered  that  the  workers  in  the  hous- 
ing study  are  volunteers.  _Every  effort  should  therefore 
be  made  to  render  their  work  as  easy  and  as  pleasant  as 
possible.  They  should  be  given  much  credit  in  the  public 
press;  their  names  should  be  printed,  and  the  housing 
work  should  be  ''played  up"  in  the  papers  throughout 
the  period  of  the  survey.  The  workers  should  preferably 
be  women,  as  they  usually  have  more  leisure  than  men, 
and  can  be  made  sufficiently  interested  and  proficient  to 
obtain  the  detailed  information  called  for  by  the  card. 
They  should,  of  course,  be  as  intelligent  as  possible.  In 
some  cases,  it  will  be  possible  to  enlist  the  aid  of  the  school 
teachers  in  the  community.  On  the  inteUigence  and  per- 
severance of  the  workers,  the  success  of  this  portion  of  the 
survey  will  depend. 

Male  Workers  to  be  Used  in  Certain  Sections.  —  Certain 
sections  of  the  city  should  be  surveyed  by  male  workers,  if 
these  sections  are  included  in  the  general  housing  survey. 
This  refers  particularly  to  the  houses  in  the  business  dis- 
trict, the  lodging  houses,  and  the  houses  that  are  located 
in  districts  where  it  might  be  dangerous  or  undesirable  for 
a  young  woman  to  work.  These  districts  should  be  covered 
by  volunteer  male  workers,  or  by  the  surveyor  himself. 

In  the  lodging  houses,  particular  attention  should  be 
given  to  windowless  rooms,  to  overcrowding,  to  the  absence 
or  inadequacy  of  toilet  facilities,  drinking  facilities,  and 
any  other  factor  that  may  have  a  direct  bearing  on  the 
health  of  the  residents. 

Surveyor  should  Study  Housing  Conditions  Personally. 

—  When  the  work  of  the  survey  is  almost  completed,  the 
investigator  should  make  a  personal  study  of  the  housing 
conditions.     A  particularly  tht)rough  study  should  be  made 


26  ORGANIZING   A  COMMUNITY 

of  the  conditions  existino;  in  the  poorer  sections.  This 
work  should  supplement  the  housing  survey  conducted  by 
the  volunteer  workers. 

The  investigator  should  enter  certain  homes,  particularly 
in  the  poorer  quarter  of  the  city,  and  become  acquainted 
with  their  conditions.  He  should  inspect  yards,  privies, 
and  wells,  and  try  to  obtain  as  thorough  a  knowledge  of 
the  general  housing  conditions  as  is  possible  during  the 
time  that  is  devoted  to  this  work.  During  this  period  the 
camera  should  be  used  frequently.  Photographs  should  be 
taken  of  conditions  in  the  home,  as  well  as  outside.  A  few 
well-defined,  purposeful,  and  intelligently  selected  photo- 
graphs will  do  more  to  bring  the  community  to  a  reahza- 
tion  of  undesirable  conditions  than  a  long  dissertation  on 
the  same  subject.  It  is  extremely  important  for  the  sur- 
veyor to  make  this  personal  study,  in  order  to  obtain  first- 
hand information.  In  writing  his  report,  he  will  be  called 
upon  to  analyze  and  interpret  the  data  collected  by  the 
housing  workers;  and  it  will  be  impossible  to  do  this  accu- 
rately and  with  vision,  unless  the  surveyor  has  actually 
seen  the  conditions  himself. 

The  surveyor  should  also  study  the  conditions  in  the 
better  parts  of  the  city,  although  this  part  of  the  investiga- 
tion need  not  be  as  complete  or  as  thorough  as  in  the 
poorer  parts.  Several  photographs  should  also  be  taken 
of  both  good  and  modest  housing  conditions,  in  order  to 
bring  out  the  good  side  of  the  housing  situation  as  well  as 
the  bad. 

It  must  be  borne  in  mind  throughout  the  work  that 
nothing  will  lessen  the  good  effect  of  the  survey  to  the 
same  degree  as  callous  criticism  and  utter  blindness  to  the 
good  things  that  abound  in  the  city.  The  surveyor  must 
remember  that  the  citizens  have  considerable  civic  pride, 
and  that  they  will  be  injured  very  deeply  if  only  the  black 
spots  are  made  visible,   and  the  brighter  spots  are  not 


SURVEYOR  SHOULD  TOUR  THE  CITY      27 

given  the  credit  they  deserve.  It  is  so  easy  to  be  merely 
the  critic  that  one  must  beware  of  the  dangers  that  beset 
such  a  course.  A  proper  mixture  of  criticism  and  com- 
mendation will  bring  about  better  results  than  the  use  of 
the  former  alone. 

Use  of  City  Inspectors  Desirable,  where  Possible.  — 
Another  method  of  accomplishing  the  housing  survey 
through  cooperative  effort  is  to  utilize  the  city  inspectors 
for  that  purpose.  If  a  housing  department  is  one  of  the 
city's  administrative  bodies,  several  inspectors  may  prob- 
ably be  obtained  from  that  source.  The  sanitary  inspectors 
of  the  health  department  may  also  be  utiUzed.  In  order 
to  make  the  housing  survey  less  irksome  and  more  efficient, 
as  many  inspectors  as  possible  should  be  obtained.  It  is 
desirable  to  conclude  this  phase  of  the  work  as  soon  as 
possible. 

Surveyor  should  Tour  the  City.  —  One  of  the  first  things 
the  surveyor  should  do,  after  his  arrival,  is  to  make  a  tour 
of  the  entire  city  in  order  to  obtain  a  bird's-eye  view  of  it. 
In  this  hasty  survey,  particular  attention  should  be  given 
to  things  of  sanitary  significance,  to  the  layout  of  the  city, 
and  the  superficial  evidences  of  its  sanitary  condition.  As 
many  notes  as  possible  should  be  made,  the  good  sections 
being  noted,  as  well  as  the  poor  ones.  It  is  well  for  the 
surveyor  to  be  accompanied  by  one  who  knows  the  city 
thoroughly,  from  long  residence  in  it.  Much  can  be  learned 
from  such  an  individual  regarding  industrial  conditions, 
housing  conditions,  and  any  special  problems  that  may 
exist. 


CHAPTER   III 

METHODS   EMPLOYED    IN    MAKING   A   PUBLIC 

HEALTH    SURVEY 

The  Sources  of  Information.  —  After  the  work  of  organi- 
zation has  been  completed,  and  the  central  committee  is 
thoroughly  acquainted  with  the  plan,  purpose  and  scope 
of  the  work,  the  actual  investigation  should  begin.  It  is 
desirable  to  become  as  intimate  with  the  prevailing  condi- 
tions as  is  possible  in  a  short  time.  To  this  end  it  is  wise 
to  interview  the  various  municipal  officials  and  private 
individuals  who  have  charge  of  the  several  functions  under 
consideration.  Very  often  it  will  be  found  that  those  who 
are  responsible  are  not  fully  acquainted  with  the  undertak- 
ing under  their  supervision.  This  is  especially  apt  to  be  so 
when  public  works  are  under  the  supervision  of  municipal 
representatives  who  have  been  elected  to  office.  Under 
the  commission  form  of  government,  each  commissioner  is 
placed  in  charge  of  certain  municipal  activities;  and  under 
almost  any  form  of  municipal  government,  the  mayor  and 
his  council  are  nominally  in  charge  of  all  the  municipal 
activities.  It  may  be  that  when  the  survey  begins,  the 
commissioners,  or  members  of  the  city  council,  have  only 
recently  been  elected  to  office,  and  hence  have  not  had  the 
opportunity  to  acquaint  themselves  with  all  the  details  of 
the  public  works  under  their  control.  It  is  possible  that 
the  elected  officials  are  not  sufficiently  interested  to  know 
their  departments  as  thoroughly  as  they  should.  It  is 
also  possible  that  they  may  not  have  the  proper  technical 
education  and  training  to  grasp  the  work.  In  no  case, 
however,  must  the  surveyor  become  discouraged,  for  it  is 

28 


THE  SOURCES  OF  INFORMATION  29 

invariably  true  that  at  least  one,  and  sometimes  several 
men,  in  the  employ  of  the  city,  can  supply  the  investigator 
with  all  the  needed  information,  and  sometimes  with  many 
details  concerning  the  particular  department  under  in- 
vestigation. Sometimes  one  individual  will  be  able  to 
give  information,  not  only  about  his  own  work,  but  also 
about  that  of  another  department.  This  is  quite  apt  to 
be  true  in  the  two  fields  of  water-supply  and  sewage-dis- 
posal. The  surveyor  must  therefore  always  be  alert  and 
take  advantage  of  his  opportunities  as  he  meets  them. 

Occasionallv  the  storv  will  come  from  several  sources, 
and  the  individual  bits  of  information  must  be  knit  together 
and  woven  into  a  single,  comprehensive  and  intelligent  nar- 
rative in  the  final  report.  Care  must  always  be  taken  to 
dissociate  beliefs  and  suppositions  from  facts;  and  facts 
alone  must  be  included  in  the  report.  The  investigator 
can  determine  which  statements  are  expressions  of  fact, 
and  which  are  not,  by  conducting  personal  investigations, 
by  studying  printed  reports  on  the  subject,  made  by  com- 
petent investigators,  and  by  recording  only  such  state- 
ments as  are  made  by  those  in  immediate  control  of  the 
works  or  the  department  in  question. 

If  the  facts  cannot  be  obtained  readily  or  accurately  as 
a  result  of  interviews  with  responsible  officials,  they  must 
be  secured  by  the  analysis  of  original  data  and  reports. 
These  records  may  not  be  in  excellent  condition;  they  may 
not  be  tabulated  or  readily  available  for  use;  and  the 
search  for  the  necessary  information  may  be  laborious  and 
irksome.  It  is  important,  in  such  circumstances,  for  the 
investigator  to  h^  cheerful  and  optimistic,  and  not  to  per- 
mit himself  to  show  a  nettled  state  of  mind.  He  must 
definitely  know  what  information  he  desires,  and  be  able 
to  explain,  if  need  be,  the  value  of  this  information  for  the 
purpose  of  the  survey. 

Care  must  be  taken  not  to  burden  the  municipal  officials 


30  MAKING  A   PUBLIC   HEALTH  SURVEY 

more  than  seems  absolutely  necessary;  and  in  no  case  is 
it  advisable  to  arouse  their  antipathy  and  animosity.  If 
possible,  they  should  be  made  to  feel  that  their  depart- 
ments are  not  under  investigation,  but  that  they  are  tell- 
ing all  the  facts  they  know,  both  good  and  bad,  for  the 
general  enlightenment  and  benefit  of  the  community. 

Surveyor  should  be  Introduced  to  Officials.  —  In  order 
to  obtain  the  best  and  most  courteous  consideration,  it  is 
desirable  to  be  introduced  to  the  municipal  officials  and 
others  who  are  to  be  interviewed,  by  some  member  of  the 
central  committee  who  is  respected  and  liked  by  these 
officials,  and  who  is  well  acquainted  with  them.  This  can 
be  done  with  greatest  profit  immediately  after  the  meeting 
of  the  central  committee,  at  which  the  investigator  has 
explained  the  nature  of  the  survey  and  what  he  hopes  it 
may  be  able  to  accomplish.  If  this  meeting  occurs  at  night, 
a  definite  appointment  should  be  made  with  some  member 
of  the  central  committee,  in  order  that  the  necessary  intro- 
ductions may  be  secured. 

Sometimes  it  will  be  possible  to  meet  many  of  the  officials 
at  the  meeting  of  the  central  committee,  and  such  an 
opportunity  should  not  be  neglected.  When  this  is  not 
possible,  the  investigator  must  be  escorted  to  the  offices  of 
the  officials  and  introduced  to  each  man  separately.  On 
these  occasions  it  is  usually  preferable  not  to  begin  the  ques- 
tioning immediately.  The  stay  with  each  official  should  be 
brief  but  long  enough  for  each  man  to  become  acquainted 
with  the  surveyor  and  for  the  latter  to  give  a  brief  and 
general  outline  of  what  he  is  seeking.  In  each  case,  the 
surveyor  should  arrange,  before  leaving,  for  a  definite 
appointment  with  the  official,  at  the  latter's  convenience. 
At  this  second  meeting  the  investigator  can  begin  to  get 
the  information  he  desires. 

If  any  official  is  not  met  during  this  period  of  introduc- 
tions, and  if  he  happens  to  be  in  charge  of  a  department 


PRECAUTIONS   IN   ASKING  QUESTIONS  31 

under  investigation,  the  surveyor  should  be  sufficiently 
prudent  to  telephone,  in  order  to  explain  his  mission,  and 
to  ask  for  a  definite  appointment.  In  no  case  is  it  advisable 
to  intrude  into  a  man's  daily  affairs  without  some  preliminary 
procedure  whereby  each  becomes  known  to  the  other  and 
a  definite  appointment  is  made.  By  observing  such  pre- 
cautions the  surveyor  is  likely  to  receive  a  more  cordial 
reception  than  if  these  preliminary  steps  were  neglected. 

Precautions  in  Asking  Questions.  —  It  is  important,  too, 
that  the  surveyor  should  know  exactly  what  information 
he  desires,  and  should  be  able  to  make  his  questions  clear, 
distinct  and  inoffensive.  Under  no  circumstances  should 
he  read  the  questions  from  a  prepared  list.  The  questions 
must  be  firmly  fixed  in  his  mind  and  must  appear  to  come 
naturally.  On  the  behavior  of  the  surveyor  will  depend 
the  treatment  he  receives.  He  is  regarded  by  the  official 
or  private  individual  as  an  expert,  and  it  is  necessary  to 
justify  this  opinion  if  the  best  results  are  to  be  obtained. 
The  questions  should  therefore  be  specific,  and  superfluous 
questions  should  be  avoided.  Very  often,  questions  must 
be  made  up  on  the  spur  of  the  moment,  as  they  are  the 
result  of  statements  made  by  the  individual  who  is  supply- 
ing the  information.  These  questions  should  be  followed 
to  their  conclusion,  in  order  that  all  the  facts  may  be 
obtained. 

It  is  obvious  that  the  surveyor  must  be  well  versed  in 
every  subject  which  he  investigates,  if  he  is  to  retain  the 
good  opinion  of  the  person  being  interviewed.  In  order 
that  the  questions  may  be  intelligent  and  specific,  a  general 
knowledge  of  the  situation  to  be  considered  should  be 
obtained  before  the  interview  takes  place.  It  is  desirable, 
therefore,  that  the  surveyor  should  acquaint  himself  with 
all  the  reports  which  have  previously  been  made.  Such 
knowledge  will  place  him  on  a  more  equal  footing  with  his 
informant,  and   the   questions   that   are    propounded  will 


32  MAKING   A  PUBLIC  HEALTH  SURVEY 

appear  in  the  character  of  a  research,  rather  than  a  mere 
quest  for  information.  The  practice  of  acquainting  one- 
self with  the  previous  reports  of  the  municipahty  should 
be  followed  in  every  case  before  the  actual  investigation 
begins. 

It  will  be  found  in  certain  cases  that  the  official  is  not 
well  versed  in  the  subject-matter  under  consideration.  In 
such  a  case  he  will  probably  be  quick  to  perceive  his  in- 
adequacy, and  will  suggest  that  the  surveyor  interview  one 
who  is  in  direct  charge  of  the  work.  Where  this  is  not  done 
at  the  initiative  of  the  official,  it  should  be  suggested  by 
the  surveyor  himself.  An  appointment  should  be  made 
with  the  individual  who  is  to  furnish  the  information,  and 
the  facts  obtained  from  him. 

Recording  Data  Obtained  from  Interviews.  —  It  is  very 
difficult  to  record  the  results  of  these  interviews  on  form- 
cards  devised  for  each  subject.  Usually  many  facts  are 
learned  which  are  not  called  for  on  the  card.  Besides,  the 
card  does  not  allow  sufficient  space  for  recording  all  the 
facts.  It  is  therefore  preferable  to  use  a  note-book  for 
recording  the  information,  and  the  type  which  is  used  by 
stenogre.ohers,  and  which  fits  comfortably  into  a  coat 
pocket,  has  been  found  to  be  very  satisfactory.  The 
process  of  obtaining  information  as  a  result  of  interviews 
is  really  reportorial  in  its  nature.  One  must  know  how  to 
write  quickly,  accurately  and  legibly,  and  to  frame  a  ques- 
tion while  the  answer  to  the  previous  one  is  being  recorded. 
The  necessity  for  quick  thinking  and  rapid  action  is  there- 
fore apparent.  The  notes  should  be  sufficiently  full,  so 
that  a  comprehensive  story  will  be  obtained  when  they  are 
written  up.  A  knowledge  of  shorthand  will  be  of  value  in 
collecting  information  in  this  way;  but  it  is  wise  to  have 
the  shorthand  notes  transcribed  shortly  after  the  interview, 
so  that  the  whole  story  may  be  recorded  while  the  notes 
are  still  fresh  in  the  mind  of  the  interviewer. 


ARRANGE   TO   VISIT   VARIOUS  PLANTS  33 

Interviews  should  Yield  Complete  Information.  —  Al- 
though it  is  desirable  not  to  occupy  more  time  with  an 
individual  than  is  absolutely  necessary,  it  is  better  to  stay 
longer  and  obtain  all  the  information  at  one  time  than  to 
trouble  the  official  with  a  second  visit.  In  order  to  be 
certain  that  all  the  information  has  been  obtained,  it  is 
now  permissible  and  advisable  to  glance  through  a  pre- 
pared outline,  to  observe  whether  all  the  points  enumerated 
have  been  covered.  If  they  have  not,  the  questioning 
may  be  resumed  on  the  spot.  If  they  have,  it  is  advisable 
to  ask  the  informant  whether  he  has  any  further  informa- 
tion on  the  subject  which  he  would  hke  to  impart,  and 
whether  there  is  any  special  problem  which  has  not  been 
brought  out,  and  which  should  be  considered  in  the  survey. 
In  this  way  it  is  often  possible  to  obtain  remarkably  com- 
plete information. 

The  Surveyor  should  Arrange  to  Visit  Various  Plants.  — 
If  there  is  any  plant,  clinic  or  other  institution  that  is  asso- 
ciated with  the  department  under  investigation,  a  definite 
appointment  should  be  made  at  this  time,  with  the  proper 
authorities,  for  permission  to  inspect  and  study  the  estab- 
lishment in  question.  Thus,  if  it  is  the  water-engineer  who 
is  being  interviewed,  an  appointment  should  be  made  to 
visit  the  water-purification  plant,  if  there  is  one;  if  it  is 
the  engineer  in  charge  of  sewers,  arrangements  should  be 
made  to  visit  the  sewer-outfalls,  and  the  sewage-disposal 
plant,  if  such  a  plant  is  in  use;  if  it  is  the  street  commis- 
sioner, arrangements  should  be  made  to  visit  the  incinerator, 
reduction  plant,  piggeries  and  dump.  Sometimes  it  will 
be  found  that  the  health  officer  has  control  over  the  collec- 
tion and  disposal  of  refuse,  so  that  permission  must  be 
obtained  from  the  latter.  Permission  will  also  have  to  be 
obtained  to  visit  the  contagious  disease  hospital,  the 
general  hospitals,  the  dairy  farms,  the  schools,  the  dispen- 
saries and  clinics,  the  public  health  laboratories  and  other 


34  MAKING  A   PUBLIC  HEALTH  SURVEY 

places  of  sanitary  interest.  Wherever  possible,  the  inspec- 
tion of  these  places  should  be  made  in  the  company  of  one 
who  understands  the  process  and  who  knows  the  location 
of  the  plant  or  building  where  the  undertaking  is  housed. 
In  this  way  much  time  will  be  saved,  and  all  the  necessary 
information  about  the  operation  of  the  process  will  be 
obtained. 

Each  Day's  Work  should  be  Planned.  —  It  will  be  to 
the  advantage  of  the  investigator  if  the  work  for  each  day 
is  thoroughly  planned  and  outlined.  On  those  days  which 
are  to  be  spent  in  inspections,  such  as  the  inspection  of 
dairy  farms  or  schools,  or  food-stores  and  restaurants,  it 
will  be  a  comparatively  simple  matter  to  occupy  the  whole 
day.  But  when  the  day  is  to  be  devoted  mostly  to  inter- 
views or  laboratory  work,  there  will  probably  be  several 
hours  for  which  no  provision  has  been  made.  As  a  rule, 
it  is  possible  to  utihze  this  time  in  copying  statistics, 
obtaining  any  maps  that  may  be  necessary  for  the  report, 
taking  photographs  illustrative  of  housing  and  general 
sanitary  conditions,  or  in  performing  the  numerous  little 
tasks  which  arise  during  the  period  of  the  survey,  and 
which  must  receive  attention.  It  is  important  that  the 
surveyor  should  be  profitably  occupied  throughout  the 
working  day. 

Interest  of  Central  Committee  should  be  Maintained.  — 
During  the  progress  of  the  survey,  it  is  desirable  that  the 
investigator  have  occasional  meetings  with  the  chairman 
of  the  central  committee,  or  with  the  secretary  of  that 
body,  if  the  latter  is  more  active  in  fostering  the  survey 
and  seems  to  have  more  time  available  for  the  work.  It 
is  important,  however,  that  other  members  of  the  com- 
mittee should  be  kept  informed  about  the  progress  of  the 
work.  Their  interest  and  cooperation  will  be  maintained 
in  this  way,  and  they  will  be  gradually  made  aware  of  the 
conditions  that  exist  and  the  means  required  to  remedy 


CENTRAL  COMMITTEE  MUST  BE   MAINTAINED      35 

them.  If  any  lasting  benefits  are  to  be  derived  from  the 
survey,  it  is  highly  important  that  the  members  of  the 
central  committee  be  gradually  educated  to  the  need  of 
them,  so  that  they  will  champion  the  work  of  the  survey 
and  be  active  in  supporting  its  recommendations.  At  the 
conferences  which  the  surveyor  should  have  with  one  or 
more  members  of  the  central  committee,  it  is  desirable  to 
outline  the  work  which  has  been  accomplished  and  to  inti- 
mate in  a  general  way  the  outstanding  facts  which  have 
been  ascertained.  Any  difficulties  which  have  been  en- 
countered during  the  work  may  also  be  discussed  at  these 
conferences,  and  some  means  for  solving  the  problem  will 
usually  be  found.  The  members  of  the  committee  are  resi- 
dents in  the  community.  They  know  the  people  and  the 
conditions  that  prevail,  and  they  can  be  expected  to  find 
ways  out  of  difficulties  which  the  surveyor,  who  is  a 
stranger  in  the  community,  would  not  be  in  a  position  to 
know. 

Organization  of  Central  Committee  must  be  Maintained 
after  the  Survey.  —  After  the  survey  is  over,  it  is  exceed- 
ingly important  not  to  permit  the  central  committee  to 
disintegrate.  During  the  progress  of  the  survey  their 
work  has  been  important,  it  is  true,  but  still  of  a  minor 
character.  At  the  conclusion  of  the  survey,  however,  they 
assume  a  position  of  extreme  importance,  for  on  their 
ability,  interest  and  cooperation  will  depend  whatever 
lasting  good  the  survey  may  accomplish.  It  is  therefore 
important  that  the  committee  be  left  with  something 
tangible  to  work  upon,  and  that  they  be  fully  instructed 
concerning  the  findings  of  the  survey.  Although  it  is  im- 
possible to  submit  a  complete  report  immediately  after  the 
termination  of  the  field  work,  it  is  possible  to  leave  with  the 
committee  a  preliminary  report  of  the  work  and  a  list  of 
some  of  the  important  recommendations  which  will  be 
made  in  the  final  report.     The  preliminary  report  should 


36  MAKING   A   PUBLIC   HEALTH  SURVEY 

preferably  be  brief,  but  it  should  also  be  concise  and  accu- 
rate, and  should  touch  on  every  phase  of  the  work  which 
has  been  studied.  Care  should  be  taken  to  emphasize  the 
good  points  as  well  as  the  bad. 

Submitting  the  Preliminary  Report.  —  One  of  the  best 
ways  to  present  the  findings  to  the  committee  is  to  call  a 
meeting  of  the  central  committee  immediately  after  the 
termination  of  the  field  work.  This  should  be  done  through 
the  chairman  or  secretary.  In  some  cases  it  will  be  pos- 
sible to  combine  the  meeting  with  a  luncheon,  while  in 
other  communities  it  will  be  necessary  to  hold  it  at  night. 

A  full  attendance  of  the  central  committee  should  be 
urged.  This  can  usually  be  obtained  without  difficulty, 
especially  if  the  survey  has  been  conducted  with  satis- 
factory publicity.  People  are  always  interested  in  results, 
and,  as  the  committee  will  expect  to  hear  the  results  at 
this  meeting,  a  satisfactory  and  even  complete  attendance 
is  assured.  Care  should  be  taken  to  invite  all  heads  of 
departments  whose  functions  and  activities  have  been  in- 
vestigated, as  well  as  any  municipal  officials  who  are  not 
members  of  the  central  committee,  and  all  others  whose 
work  is  to  be  criticized  or  discussed.  This  is  desirable  in 
order  to  permit  the  individuals  whose  work  is  under  con- 
sideration to  learn,  at  first  hand,  the  results  of  the  survey, 
and  to  have  an  opportunity  to  refute  any  statement  that 
has  been  made.  Since  the  investigator  is  to  make  his 
findings  public  at  this  meeting,  it  is  obvious  that  he  should 
be  certain  of  his  facts  and  be  able  to  substantiate  them  if 
the  occasion  should  arise. 

Several  copies  of  the  preliminary  report  should  be  left 
with  the  central  committee,  in  order  that  they  may  be 
able  to  refer  to  them,  after  the  meeting  is  over  and  the 
investigator  has  gone.  After  the  preliminary  report  has 
been  presented,  it  is  well  to  enumerate  several  of  the  very 
important  recommendations  which  can  be  made  as  a  result 


FINAL  REPORT  37 

of  the  survey,  and  to  urge  the  committee  to  begin  definite 
action  aiming  at  their  adoption.  Numerous  questions  and 
confusions  will  doubtless  arise,  and  the  investigator  should 
take  this  opportunity  to  clear  them  up  if  possible.  The 
meeting  should  end  with  the  appointment  of  a  committee 
or  committees  to  consider  the  report  and  to  devise  ways 
and  means  for"  the  adoption  of  the  recommendations. 

Final  Report  should  be  Made  as  Soon  as  Possible.  — 
Inasmuch  as  there  will  be  a  tendency  to  defer  any  vigorous 
action  until  the  final  and  complete  report  is  in  the  hands 
of  the  committee,  it  is  important  that  this  report  should 
be  completed  as  soon  after  the  termination  of  the  field 
work  as  possible.  The  benefit  to  be  derived  from  the  sur- 
vey will  vary  directly  as  the  promptness  with  which  the 
report  is  published.  At  the  end  of  the  field  work,  the 
community  is  usually  fully  awake  to  the  existence  of  the 
survey,  and  to  its  hopes,  purposes  and  accomplishments. 
They  are  therefore  in  a  receptive  mood  toward  its  results 
and  recommendations.  It  is  because  of  this  peculiar  psy- 
chological condition,  that  the  final  report  should  be  com- 
pleted as  soon  after  the  field  work  as  possible. 


CHAPTER   IV 

GENERAL   INFORMATION   ABOUT   THE 

COMMUNITY  1 

What  Everybody  Wants  to  Know  about  a  Place.  — 
Doubtless  everybody  has  had  the  experience  of  visiting 
some  strange  city,  either  in  this  country  or  in  foreign  lands. 
If  the  city  visited  is  far  away,  certain  questions  will  surely 
be  asked  of  the  traveler  on  his  return.  If  a  lecturer  has 
returned  from  a  distant  city  or  a  foreign  land,  and  is  re- 
counting his  experiences,  the  same  questions  will  probably 
be  present  in  the  minds  of  his  auditors.  Some  of  these 
questions  are  as  follows:  Where  is  the  city  located?  In 
what  relation  is  it  to  other  places  that  we  know  or  have 
heard  about?  Is  it  located  in  hilly  or  mountainous  coun- 
try, or  in  great  extending  plains?  What  kind  of  weather 
does  one  experience  there?  What  is  the  character  of  the 
people?  What  industries  prevail?  Is  it  a  wealthy  com- 
munity? Are  the  transportation  facilities  satisfactory? 
What  is  the  character  of  the  houses,  the  hotels,  the  roads, 
and  public  institutions? 

These  and  numerous  other  questions  arise  in  the  minds 
of  most  people,  regarding  any  place  that  is  not  familiar. 
It  is  therefore  appropriate  and  important,  in  a  thorough 
public  health  survey  of  a  community,  to  record  some 
general  information  about  the  city,  its  history,  its  location, 

1  This  chapter  was  written  primarily  at  the  suggestion  of  Professor 
George  C.  Whipple  of  Harvard  University.  The  material  for  the 
chapter  has  also  been  obtained  from  Professor  Whipple's  article  on 
"World  Sanitation:  A  Twentieth  Century  Possibility,"  in  Vol.  I, 
No.  1,  of  the  International  Journal  of  Public  Health,  July,  1920. 

38 


IMPORTANT  PUBLIC   HEALTH  SIGNIFICANCE        39 

its  climate  and  its  people,  in  order  to  give  a  complete 
description  of  the  community,  and  to  answer  these  ele- 
mentary questions  which  are  of  interest  to  all  of  us,  when 
the  life  and  activities  of  a  city  are  under  consideration. 

General  Conditions  have  Important  Public  Health  Sig- 
nificance. —  This  information  is  also  important  from  the 
public  health  point  of  view  because  of  the  marked  sig- 
nificance which  certain  factors  like  climate,  locality  and 
mechanical  conveniences  may  have  on  the  health  of  the 
people.  In  fact,  Ellsworth  Huntington  has  attempted  to 
show  in  his  fascinating  and  stimulating  book,  ''Climate  and 
Civilization,"  that  the  type  of  civilization  which  prevails 
in  a  given  locahty  is  dependent  upon  the  climate.  Public 
health  workers  have  also  learned  of  the  relationship  of 
hookworm  and  malaria  to  certain  lines  of  latitude,  of  the 
prevalence  of  plague  in  sea-port  communities,  of  the 
relationship  of  malaria  and  yellow  fever  to  swamp  land  and 
the  use  of  open  cisterns,  of  the  relationship  of  typhus  to 
poverty,  overcrowding,  and  the  lack  of  proper  hygienic 
habits,  and  of  numerous  other  similar  important  relation- 
ships. More  recently,  we  have  come  to  realize  the  pro- 
found, significant  relationship  that  exists  between  indus- 
tries and  working  conditions,  and  the  health  of  the  worker. 
There  is  a  distinct  connection  between  various  industries 
and  tuberculosis,  between  various  occupations  and  hazards 
to  life  and  limb,  between  various  kinds  of  employment  and 
industrial  fatigue. 

It  is  therefore  apparent  that  these  general  conditions, 
which  are  most  often  taken  for  granted,  have  a  direct  and 
important  effect  on  the  public  health.  Similarly,  the 
presence  of  adequate  and  rapid  transportation  facilities 
may  have  an  important  bearing  on  the  quantity,  the 
variety,  and  the  freshness  of  the  foods  on  hand.  The 
presence  of  adequate  transportation  facilities  may  deter- 
mine whether  a  community  is  amply  and  properly  fed  and 


40  INFORMATION   ABOUT  THE  COMMUNITY 

whether  it  is  properly  clothed  and  sheltered.  These  are 
the  elementary  necessities  of  life  and  their  availability  is 
extremely  important  from  the  public  health  standpoint, 
for  it  determines  whether  the  people  are  provided  with 
those  things  that  are  necessary  to  build  up  and  maintain 
the  vital  resistance,  and  thus  ward  off  attacks  of  disease. 
Similarly  the  degree  and  extent  of  poverty  affect  the  pub- 
lic health,  for  the  lack  of  ability  to  provide  the  essentials 
for  keeping  the  body  fit  results  in  an  increased  susceptibility 
to  disease. 

The  public  health  worker  is  only  too  prone  to  regard  the 
constant  struggle  against  disease  as  a  battle  against  the 
specific  microbe.  Only  too  rarely  does  he  consider  those 
other  general  factors  which  cannot  be  measured  with  the 
ocular  micrometer,  and  whose  effects  cannot  be  nullified 
by  the  use  of  vaccines,  antitoxins,  and  immune  sera,  but 
which,  nevertheless,  are  an  important  part  of  our  environ- 
ment and  affect  us  constantly  throughout  our  lives.  The 
consideration  of  these  general  factors  has  a  logical  place 
in  the  public  health  survey,  for  various  reasons.  The 
general  information  that  should  be  obtained  is  indicated 
by  the  following  questions. 

The  Locality 

What  is  the  name  of  the  city?  In  what  state  is  it 
located?  Of  what  nation  is  this  state  a  part?  Where  is 
the  state  located  with  reference  to  other  states  or  familiar 
places  in  this  country?  In  what  portion  of  the  state,  is 
the  city  under  consideration  located  ?  What  are  its  latitude 
and  longitude? 

What  is  its  area?  Obtain  a  map  showing  the  geographi- 
cal relation  of  this  city  to  other  places  in  the  same  state 
or  country,  and  another  showing  the  detailed  layout  of  the 
city  itself.     Is  the  city  surrounded  by  hills  or  mountains? 


THE   CLIMATE  41 

If  so,  name  and  describe  them.  Is  the  city  in  a  valley  or  a 
plain?  Is  it  inland  or  on  the  seaboard?  Is  it  located  on 
any  river,  lake  or  other  large  body  of  water  ?  What  is  the 
elevation  of  the  city?  Are  there  any  marshes?  If  so, 
locate  them  and  determine  their  extent. 

What  is  the  character  of  the  top-soil?  Of  the  subsoil? 
Are  there  any  significant  features  associated  with  the 
geology  of  the  city?  What  is  the  character  of  the  vege- 
table life  in  the  state  ?     What  animals  and  insects  abound  ? 

Is  the  surrounding  land  used  for  agriculture?  If  so, 
what  crops  are  grown?  Is  the  land  used  for  grazing?  If 
so,  what  animals  are  maintained  in  this  way?  Is  the  land 
fertile?     Is  it  artificially  irrigated? 

Has  the  state  much  water-power?  Has  it  been 
developed  ? 

Has  the  state  any  mines?  What  minerals  or  metals 
are  obtained?  What  are  the  other  mineral  resources  of 
the  land? 

What  railroads  enter  the  city?  Is  the  city  joined  by 
water  to  the  outside  world?  Has  it  steamboat  transpor- 
tation facilities  ?  Are  the  transportation  facilities  adequate 
and  satisfactory? 

Is  the  city  laid  out  according  to  a  definite  plan?  Does 
this  plan  seem  satisfactory  ?  Are  there  many  well-defined 
streets?  Are  the  majority. of  the  streets  paved?  Has  the 
city  a  satisfactory  and  extensive  park  system?  Are  the 
streets  artificially  lighted  at  night?  Are  the  houses  sup- 
plied with  gas?  Are  they  supplied  with  electricity?  Are 
the  hotel  facilities  adequate  and  satisfactory? 

The  Climate 

Are  daily  observations  made  bj^  trained  workers,  of  the 
temperature,  humidity,  rainfall,  winds,,  etc.  ?  If  so,  how 
long  have  such  records  been  kept  ?     What  have  been  the 


42  INFORMATION   ABOUT  THE   COMMUNITY 

average  monthly  maximum,  minimum  and  mean  tempera- 
tures? What  has  been  the  average  monthly  maximum, 
minimum  and  mean  humidity  ?  What  is  the  average  annual 
rainfall?  What  is  the  average  monthly  rainfall  through- 
out the  year?  What  is  the  greatest  twenty-four-hour 
rainfall  that  has  ever  occurred?  What  is  the  maximum 
rate  of  rainfall  ever  recorded?  Are  there  any  pronounced 
wet  and  dry  periods  during  the  year  ?  What  is  the  amount 
of  snow  in  the  vicinity?  AVhat  is  the  amount  of  fog? 
Does  the  temperature  fall  low  enough  to  form  natural 
ice? 

What  are  the  prevailing  winds  at  different  periods  of  the 
year  ?  From  what  direction  do  the  cool  winds  come  in  the 
summer?  What  is  the  average  wind-velocity  during  the 
various  seasons?  What  is  the  maximum  wind-velocity 
during  the  various  seasons?  Do  tornadoes  occur  in  the 
city  and  state  under  consideration?  What  is  the  usual 
frequency  of  their  occurrence? 

Are  bright,  sunny  days  the  rule,  or  are  they  infrequent? 

The  People 

Methods  of  obtaining  specific  information  regarding  the 
population  will  be  discussed  in  the  chapter  on  Vital  Statis- 
tics. The  questions  recorded  here  cover  only  the  points 
which  are  not  taken  up  in  that  chapter. 

What  is  the  density  of  population  per  acre?  The  aver- 
age, maximum,  and  minimum  density  in  the  built-up  sec- 
tion of  the  city  should  be  given,  if  statistics  are  available. 
If  large  tenement  houses  exist,  it  is  also  desirable  to  record 
the  number  of  people  in  some  of  these.  From  the  housing 
survey,  it  will  also  be  possible  to  determine  the  size  of  the 
families  throughout  the  city.  If  there  is  anything  striking 
about  these  statistics  that  fact  should  be  emphasized. 

What  are  the  predominating  nationalities  of  the  people? 


THE   PEOPLE  43 

What  are  the  important  rehgious  sects  in  the  city,  and 
which  have  the  most  adherents? 

What  is  the  general  degree  of  education  of  the  people? 
Is  there  a  large  amount  of  illiteracy?  How  many  news- 
papers are  published  in  the  city?  In  what  languages  do 
they  appear? 

What  is  the  nature  of  the  political  organization  of  the 
people?     Describe  the  existing  system  of  government. 

What  are  the  prevailing  industries  and  occupations  in 
the  city?  What  are  the  prevailing  hours  of  employment? 
Is  the  average  wage  sufficiently  high  to  enable  the  people 
to  live  in  decency  and  modest  comfort?  To  what  extent 
are  women  employed  in  industry?  In  what  particular 
industries  are  they  employed  ?  To  what  extent  are  children 
employed  in  industry?  In  what  particular  industries  are 
they  employed? 

What  is  the  extent  of  pauperism  in  the  city?  Is  the 
ownership  of  land  and  home  extensive,  or  are  the  people 
mainly  renters  ? 


CHAPTER   V 
WATER-SUPPLY 

Adequate  and  Safe  Water-Supply  Essential  for  Every 
Community.  —  In  order  to  live  and  grow,  every  com- 
munity must  liave  an  adequate,  wholesome  and  safe  water- 
supply.  This  is  a  need  which  communities  have  recog- 
nized for  ages  past;  cities  used  to  develop  around  those 
sources  of  supply  which  were  ample  and  safe,  and  where 
such  a  supply  was  not  available,  much  money  and  effort 
were  expended  to  bring  the  necessary  water  to  the  city. 
Witness  the  old  Roman  aqueducts,  which  were  built  at  a 
great  cost  of  labor  and  money  in  order  to  bring  a  good  and 
ample  supply  of  water  to  Rome.  New  York  City  affords 
a  more  modern  example,  for  it  has  recently  spent  millions 
of  dollars  to  increase  its  available  water-supply,  in  order 
to  meet  the  rapid  growth  of  the  city.  The  land  from 
which  the  water  runs  off,  and  which  is  commonly  called 
the  watershed  or  drainage  area,  is  freed,  as  much  as  possible, 
from  human  habitation  and  industr}^  This  is  done  for  the 
purpose  of  protecting  the  water-supply  from  pollution  and 
possible  infection. 

Development  of  a  Municipal  Supply.  —  The  history  of 
water-supply  development  is  much  the  same  for  all  large 
communities.  When  the  community  is  small,  each  family 
usually  obtains  its  water  from  a  private  well.  Sometimes 
a  numlxT  of  families  obtain  their  water-supply  from  the 
same  well,  while  in  still  other  cases  a  group  of  wells  may 
serve  as  the  source  of  supply  for  the  entire  settlement.  As 
the  conmiunity  grows,  the  well  water-supply  usually  be- 
comes inadequate,   and   a  new  source  of   water   must   bo 

44 


KNOWLEDGE  OF  WATER-SUPPLIES  ESSENTIAL     45 

found.  This  is  generally  obtained  from  a  nearby  stream 
or  lake  or  from  the  ground.  Later  this  source  of  supply 
may  become  inadequate,  and  possibly  also  polluted,  with 
the  human,  animal  and  industrial  wastes  of  the  city,  and 
it  therefore  becomes  necessary  to  draw  water  from  still 
another  source,  usually  a  stream  or  reservoir  located  at  a 
considerable  distance  from  the  city.  Sometimes  the  water 
is  purified  by  filtration  or  disinfection,  or  by  both  processes 
combined.  Sometimes  adequate  storage  is  provided  to 
render  the  water  safe.  There  are  cases,  however,  where 
the  raw,  untreated  water  is  considered  safe  for  drinking 
purposes,  and  the  water  is  pumped  directly  into  the  mains. 

Adequate  Water-Supply  Necessary  for  Clean  Habits.  — 
Not  only  is  an  adequate  water-supply  necessary  to  main- 
tain industries  and  to  satisfy  the  demands  of  the  body  for 
water,  but  it  is  also  necessary  in  order  to  provide  for  the 
daily  requirements  of  a  hygienic  life.  It  is  very  difficult 
to  practise  cleanliness  if  an  adequate  supply  of  water  is 
not  readily  available.  Since  the  relationship  of  clean 
hands,  clean  food,  clean  utensils,  clean  linen  and  a  clean 
home  to  good  health  and  decent  living  has  been  definitely 
established,  the  necessity  for  furnishing  an  adequate  and 
readily  available  water-supply  is  imperative.  Where  the 
water-supply  is  not  adequate,  or  where  water  can  be 
obtained  only  with  a  considerable  expenditure  of  time  and 
labor,  the  observance  of  the  elementary  principles  of 
hygiene  will  be  neglected.  Urban  residents  are  apt  to 
forget  this  fact  when  the  unclean  habits  of  certain  rural 
residents  are  observed.  If  the  people  are  to  be  expected 
to  practise  clean  habits,  as  public  health  workers  are  con- 
tinually urging  them  to  do,  it  is  important  to  realize  that 
the  mechanical  facilities  which  are  necessary  must  be 
adequate  and  easily  available. 

Knowledge  of  Water-Supplies  is  Essential.  —  Having 
made  the  acquaintance  of  the  water  commissioner  or  any 


46  WATER-SUPPLY 

other  person  who  is  thoroughly  famiUar  with  the  water- 
supply  system  of  the  community,  and  the  methods  by 
which  the  water  is  treated,  the  health  surveyor  is  now 
ready  to  make  a  definite  appointment  in  order  to  get  cer- 
tain data.  Since  it  will  be  necessary  for  him  to  question 
his  informant,  the  surveyor  should  not  only  be  thoroughly 
familiar  with  the  general  subject  of  water-supplies,  but 
should  also,  if  possible,  be  familiar  with  the  past  reports 
and  special  studies  made  on  the  water-supply  under  con- 
sideration. Very  often  this  is  not  possible,  but,  where  it 
is,  the  surveyor  will  be  so  well  informed  regarding  the 
development  of  the  present  water-supply  system  and  its 
particular  problems,  that  he  will  be  able  to  obtain  any 
additional  information  concerning  the  supply  with  little 
delay.  Furthermore,  it  is  always  interesting  to  the  local 
official  to  discuss  his  problems  with  an  expert,  and  to  get 
advice  regarding  their  solution.  Under  such  cricumstances, 
the  surveyor  is  cordially  welcomed,  and  it  is  usually  made 
possible  for  him  to  study  the  water-supply  problem  in 
complete  detail. 

Maps  of  Water  System  and  Purification  Plant.  —  Infor- 
mation regarding  the  purification  works  and  the  details  of 
construction  and  operation  should  not  be  sought  at  this 
interview.  They  should  be  obtained  from  the  superin- 
tendent of  the  water-purification  plant,  when  the  surveyor 
makes  his  inspection.  It  may  be  possible,  during  the  inter- 
view at  the  office  of  the  water  department,  to  obtain  a  map 
showing  the  extent  of  the  water  system,  and  also  those 
portions  of  the  city  not  yet  supplied  with  water.  If  it  is 
possible  to  obtain  a  map  which  traces  the  water  from  its 
source  to  the  city,  this  will  also  be  of  value.  These  maps, 
together  with  a  map  showing  the  plan  of  the  water-purifica- 
tion plant,  should  be  included  in  the  final  report. 


WATER-CONSUMPTION  47 

Information  to  be  Obtained  by  Surveyor 

The  following  is  a  set  of  typical  questions  which  may  be 
used  by  the  surveyor  to  obtain  the  necessary  information. 

Source  of  Supply.  —  What  is  the  source  of  supply  ?  If 
a  stream,  where  is  it  located  ?  If  a  lake  or  reservoir,  where 
is  the  lake  or  reservoir  located  ?  If  a  well  or  series  of  wells, 
where  are  these  located? 

Storage.  —  Is  the  water  stored  before  treatment  ?  If  so, 
where  is  the  storage  reservoir  located?  Is  the  reservoir 
formed  by  a  dam?  If  so,  what  is  the  type  of  construction 
of  the  dam?  Where  is  the  dam  located?  When  was  it 
built?  By  whom  was  it  built?  What  are  the  dimensions 
of  the  dam?     What  is  the  capacity  of  the  reservoir? 

Adequacy  of  the  Supply.  —  Does  the  city  ever  suffer  from 
an  inadequate  water-supply?  If  so,  has  this  shortage 
occurred  recently?  Does  the  shortage  occur  frequently? 
What  have  been  the  minimum,  maximum  and  mean 
periods  during  which  the  shortages  have  lasted?  Is  there 
any  additional  supply  that  can  be  used  during  such  periods  ? 
If  so,  what  is  the  source,  purity,  and  volume  of  this  supply  ? 

Method  by  which  the  Water  Reaches  the  City.  —  Does 
the  water  flow  to  the  city  by  gravity?  Is  the  water 
pumped  ?  If  so,  at  what  points  en  route  is  it  pumped  ? 
To  what  point  is  the  water  pumped  ?  What  is  the  capacity 
of  each  pump  employed?  What  is  the  capacity  of  each 
reservoir  into  which  the  water  is  pumped  ?  Does  the  water 
flow  by  gravity  from  each  of  these  reservoirs? 

Water-Consumption.  —  What  is  the  mean,  maximum 
and  minimum  daily  water-consumption  of  the  community  ? 
How  has  this  been  determined?  Has  it  been  determined 
by  a  Venturi  meter  or  other  similar  device,  or  by  observing 
the  number  of  pump-plunger  displacements?  What  is  the 
mean,  maximum  and  minimum  per  capita  water-consump- 
tion rate  in  the  community?     The  surveyor  will  have  to 


48  WATER-SUPPLY 

determine  these  rates  from  the  total  number  of  gallons  of 
water  used  per  day  and  the  best  estimated  population  of 
the  city,  if  the  figures  are  not  already  available. 

Treatment  and  Supervision.  —  Is  the  water  treated  ?  If 
so,  what  methods  are  employed?  How  many  men  are 
employed  at  the  purification  plant  ?  Is  the  man  in  charge 
a  trained  purification  plant  operator? 

The  Distribution  System.  —  Is  the  water  pumped  from 
the  purification  plant  to  the  city?  What  is  the  capacity 
of  each  availal:>le  pump?  Are  enough  pumps  available  to 
meet  the  normal  demands  of  the  city,  should  one  have  to 
be  shut  down  for  repairs?  What  are  the  sizes  of  the  pipes 
employed  to  conduct  the  water  to  the  city?  What  is  the 
total  length  of  each  size  employed  ?  Trace  the  progress  of 
the  water-carriage  system  from  the  purification  plant  to 
the  city.  What  portions  of  the  distribution  system  are 
particularly  safeguarded  against  interruption  of  the  flow  of 
water?  How  is  this  accomplished?  Describe  any  other 
method  which  the  city  employs  in  order  to  insure  a  normal 
su])ply  of  water  at  all  times. 

Reserve  SuppUes.  —  After  leaving  the  pumping-station, 
is  the  water  pumped  directly  to  the  consumer,  or  is  it  first 
sent  to  a  stand-pipe  or  a  storage  reservoir  in  the  city?  If 
the  water  is  transmitted  to  the  city  directly,  does  the  city 
maintain  a  reserve  supply  in  the  form  of  a  stand-pipe  or  a 
reservoir?  Is  the  stand-pipe  or  storage  reservoir  main- 
tained for  any  specific  purpo.  e,  such  as  an  unusual  demand 
in  case  of  large  fires,  or  foi-  an  inadequacy  in  the  regular 
supply?  What  volume  of  water  is  available  from  each  re- 
serve supply? 

If  a  stand-pipe  or  a  storage  reservoir  exists  in  the  cit}^, 
ascertain  its  location.  What  is  its  elevation?  What  is 
the  maximum  and  minimum  elevation  of  the  water  in  the 
stand-pipe  or  the  reservoir,  or  both?  What  is  the  maxi- 
m\mi,  minimum,  and  mean  amount  of  water  in  the  stand- 


WATER-PURIFICATION  PLANT  INSPECTED  49 

pipe,  or  reservoir  or  both  ?  What  are  the  dimensions  of 
the  reservoir?  Of  the  stand-pipe?  Of  both?  Of  what 
materials  are  they  built? 

Pressure  Maintained.  —  What  are  the  mean,  maximum 
and  minimum  pressures  maintained  in  different  parts  of  the 
city?  Is  there  any  arrangement  with  the  fire  department, 
whereby  the  purification  plant  operator  is  informed  imme- 
diately of  the  necessity  of  increasing  the  pressure?  If  so, 
to  what  point  can  the  pressure  be  increased  ?  When,  how, 
and  to  what  point  is  the  pressure  increased  ? 

Ownership  of  the  Supply.  —  Is  the  water-supply  system 
owned  by  the  city,  or  is  it  privately  owned  ?  If  the  latter, 
what  company  or  organization  is  the  owner?  Under  what 
arrangement  with  the  city  is  it  operating? 

Use  of  Meters.  —  Is  the  water-supply  metered  ?  If  so, 
what  percentage  of  the  water  is  metered?  What  percent- 
age of  the  service  is  metered?  How  many  meters  are  in 
use?  What  is  the  schedule  of  rates  at  which  water  is  sold 
in  the  community? 

Extent  to  which  City  is  Supplied  with  Water.  —  What 
portion  of  the  city  is  supplied  with  water?  In  what  por- 
tions of  the  city  is  the  public  water-supply  not  available? 
What  is  the  population  thus  affected?  Determine  the 
percentage  of  the  total  population  thus  affected.  Is  it 
planned  to  extend  the  water-supply  system  to  these  un- 
served parts  of  the  city  in  the  near  future  ?  What  are  the 
present  sources  of  supply  for  residents  in  those  portions 
of  the  city  where  the  public  supply  is  not  available? 

Water-Purification  Plant  should  be  Inspected.  —  The 
answers  to  the  above  questions  can  be  obtained  from  an 
interview  with  some  responsible  person  in  the  water  depart- 
ment. It  will  be  observed  that  the  details  of  the  operation 
and  construction  of  the  purification  plant  have  not  been 
considered  in  the  interview  with  the  commissioner  or  the 
superintendent  of  the  water  department.     That  informa- 


50  WATER-SUPPLY 

tion  should  be  obtained  from  the  superintendent  of  the  water- 
purification  plant,  as  he  is  the  one  who  is  most  thoroughly 
versed  in  that  phase  of  the  water-supply  problem. 

The  interview  with  the  water  commissioner  or  the  water 
superintendent  should  be  immediately  followed  by  a  visit 
to  the  water-purification  plant.  It  is  important  to  make  a 
definite  appointment  for  this  inspection.  During  the  in- 
spection, the  surveyor  should  trace  the  treatment  of  the 
water  from  the  point  of  intake  to  the  point  of  delivery  to 
the  city  mains.  Sometimes  the  individual  who  furnished 
the  information  to  the  questions  recorded  above  will  also 
be  best  qualified  to  answer  the  questions  which  follow. 
This  is  quite  apt  to  be  the  case,  particularly  in  smaller 
towns.  In  larger  communities,  a  special  superintendent  is 
usually  in  charge  of  the  operation  of  the  purification  plant. 

The  Water-Purification  Plant 

The  following  are  questions  which  may  be  used  by  the 
surveyor  in  obtaining  information  regarding  the  treatment 
of  the  water. 

The  Watershed.  —  What  precautions  are  taken  to  main- 
tain the  best  sanitary  condition  of  the  watershed?  Is  the 
watershed  under  the  jurisdiction  of  the  local  authorities? 
What  is  the  estimated  population  on  the  watershed  ?  Does 
the  source  of  water  receive  known  pollution,  such  as  the 
untreated  sewage  of  a  city  upstream,  or  the  washings  from 
surface  privies?  How  distant  is  the  nearest  important 
source  of  pollution?  Does  this  represent  a  menace  to  the 
safety  of  the  local  water-supply?  What  are  the  sanitary 
rules  and  regulations,  if  any,  which  are  in  force  on  the 
watershed,  aiming  to  reduce  the  pollution  of  the  water- 
supply  to  a  minimum?  Is  any  provision  made  to  enforce 
these  rules?  Are  the  sources  of  pollution  regularly  in- 
spected?    How  often  are  these  inspections  made? 


Fig.  1.    Location  of  water  intake  for    Tulsa,    Oklahoma,   in    the 
Arkansas  river.  (^1) 


52 


WATER-SUPPLY 


The  Water  Intake.  —  Where  is  the  intake  for  the  water- 
supply  located  ?  How  man}^  intakes  are  available  ?  Where 
is  each  located?  How  many  are  in  use  at  the  same  time? 
What  precautions  arc  taken  to  keep  out  large  bodies  of 
foreign  materials?  Is  the  purification  plant  supplied  by 
gravity?  If  not  what  is  the  capacity  of  the  pumps  used 
to  draw  the  water  into  the  plant?  Are  extra  pumping 
facilities  available,  in  case  repairs  become  necessary? 

Methods  of  Treating  Water.  —  Methods  of  treating  water 
include  storage,  plain  sedimentation,  coagulation,  softening, 


■fif 


S?^- 


r 


■•:'^mm 

ii&iiSl»^ll 

IHli  ' 

EUS^^Mi.:^^           ■          ^ 

'^''       '"^VHH 

iuBfi! 

lipi**2i^ 

■■■HH 

^ylH^^H 

I^^^H 

^^^^^^^^H 

H 

H 

^H 

^M 

H 

^H 

*  «  -ML..  Mm. 
1  1  7   ^ 


'**^, 


*^ 


Fig.  2.  Subsiding  basin  used  for  removing  suspended  matter  in 
water  after  the  addition  of  chemical  coagulants.  Most  of  the  suspended 
jnatter  in  the  water  settles  out  in  the  basin. 


slow  sand  filtration,  rapid  sand  filtration,  and  disinfection. 
Some  communities  will  use  one  method,  and  some  another, 
while  some  will  use  a  combination  of  several  of  the  methods 
enumerated.  Thus,  for  example,  one  community  may 
employ  chemical  coagulation,  water  softening,  rapid  sand 
filtration  and  final  disinfection.  Another  may  employ 
plain  sedimentation,  slow  sand  filtration  and  disinfection. 


SEDIMENTATION  53 

Still  another  community  may  employ  disinfection  alone, 
and  another,  storage  alone.  Even  where  only  disinfection 
or  sedimentation  is  employed,  the  methods  involved  may 
vary.  Water  may  be  disinfected  by  using  chlorine  gas, 
hypochlorite,  ozone  "or  some  other  medium.  Similarly, 
the  sedimentation  of  water-supplies  may  be  conducted  in 
tanks  of  varied  construction.  Each  specific  type  of  tank 
will  have  to  be  studied  by  the  surveyor,  and  the  reasons 
for  its  peculiar  design  must  be  ascertained  from  the  super- 
intendent of  the  water-purification  plant. 

Since  the  commonest  methods  of  disinfection  are  those 
which  depend  on  chlorine  gas  or  the  chlorine  derived  from 
sodium  or  calcium  hypochlorite,  the  questions  which  are 
given  below  under  the  head  of  disinfection  will  consider 
these  two  methods  only. 

Sedimentation.  —  How  many  sedimentation  tanks  are 
available?  What  type  of  subsiding-basin  is  employed? 
Of  what  materials  are  the  tanks  made?  What  are  the 
dimensions  of  each?  What  is  the  capacity,  in  gallons,  of 
each  tank  up  to  the  water-line? 

What  are  the  minimum,  maximum  and  mean  amounts 
of  settling  matter  in  the  raw  water?  How  is  the  amount 
of  settling  matter  in  the  water  determined?  What  is  the 
period  of  sedimentation  in  this  test?  What  is  the  period 
of  sedimentation  employed  in  practice?  What  are  the 
maximum,  minimum  and  mean  amounts  of  settling  matter 
removed  by  sedimentation?  How  is  the  settHng  matter 
removed  from  the  tanks?  How  is  the  settling  matter, 
which  is  removed,  finally  disposed  of? 

Is  the  operation  of  the  tanks  controlled  by  scientific  tests  ? 
How  often  are  these  tests  made  ?     What  tests  are  employed  ? 

How  often  are  the  tanks  cleaned?  Are  reserve  tanks 
available  so  that  the  normal  amount  of  water  under  treat- 
ment is  not  diminished,  when  some  of  the  tanks  are  being 
cleaned? 


54 


WATER-SUPPLY 


Is  there  anything  concerning  the  construction  or  opera- 
tion of  the  tanks,  whicli  is  unusual  and  worthy  of  special 
mention,  such  as  the  presence  of  baffles,  or  the  division  of 
each  tank  into  two  or  more  compartments  by  longitudinal 
walls?  Where  are  the  inlet  and  outlet  located?  Are  they 
so  arranged  as  to  give  the  maximum  storage,  or  is  there  a 
short  circuiting  between  inlet  and  outlet? 


Fig  3.     Clear  well  or  filtered  water  basin  used  to  receive  the  water 
after  it  is  filtered.     The  water  is  pumped  from  this  basin  to  the  city. 

Chemical  Coagulation.  —  How  many  coagulating  basins 
are  available?  What  type  of  coagulating  basin  is  em- 
ployed? Of  what  material  are  the  basins  made?  W^hat 
are  the  dimensions  of  each  ?  What  is  the  capacity  of  each, 
up  to  the  water-line? 

What  chemicals  are  used  as  coagulants  ?  What  chemicals 
are  used  for  softening,  if  the  water  is  so  treated?  How 
much  of  each  is  used?  Do  the  amounts  vary  on  different 
days,  and  during  different  periods  of  the  year?  Are 
chemical  examinations  made  to  determine  the  amounts  of 
coagulating  materials  which  are  to  be  added?     How  often 


CHEMICAL  COAGULATION 


55 


are  these  tests  made?  Are  the  tests  made  by  a  rcHable 
person  who  seems  to  be  trained  for  the  work? 

How  are  the  chemicals  added?  Are  they  added  dry,  or 
in  solution?  Do  the  chemicals  enter  the  water  at  a  point 
where  the  greatest  benefit  will  be  derived  from  them? 
What  provision  is  made  for  bringing  the  chemicals  into 
intimate  contact  with  the  water?  What  is  the  period  of 
mixing  employed?  AVhat  is  the  period  of  coagulation 
employed  ? 

What  are  the  minimum,  maximum  and  mean  amounts 
of  suspended  matter  in  the  raw  water?     By  what  test  is 


Fig.  4.  Outlet  half  of  one  of  the  sedimentation  basins  at  the  Okla- 
homa City  water  works.  The  tank  has  been  emptied  and  cleaned. 
The  trough  in  the  floor  of  the  tank  leads  to  the  sewer,  and  is  used  to 
carry  off  the  sediment  when  the  tank  is  cleaned. 


this  determined,  and  over  what  period  of  time  does  it 
extend?  WTiat  are  the  maximum,  minimum  and  mean 
amounts  of  suspended  matter  removed  by  coagulation? 
What  percentage  of  the  suspended  matter  is  removed  by 


56  WATER-SUPPLY 

coagulation?  How  is  this  coagulated  suspended  matter 
removed  from  the  basins?  What  is  the  final  disposal  of 
the  sludge  ? 

How  often  are  the  ])asins  cleaned  ?  Are  reserve  basins  avail- 
able, so  that  the  normal  amount  of  water  under  treatment  is 
not  diminished,  when  some  of  the  basins  are  being  cleaned? 

Is  there  anything  concerning  the  construction  or  opera- 
tion of  the  basins,  which  is  unusual  and  worthy  of  special 
mention,  such  as  the  presence  of  baffles?  Where  are  the 
inlet  and  outlet  located?  Are  they  so  arranged  as  to  give 
a  sufficiently  long  pei'iod  of  coagulation,  or  is  there  short 
circuiting  between  inlet  and  outlet? 

Slow  Sand  Filtration.  —  How  many  slow  sand  filters  are 
available  ?  Wlien  were  the  earliest  built  ?  Have  any  new 
units  been  added  since  then  ?  If  so,  how  many,  and  when  ? 
What  is  the  area  of  each  unit  ? 

What  kind  of  sand  is  employed?  What  is  the  total 
depth  of  sand?  What  is  the  effective  size  of  the  sand? 
What  is  the  uniformity  coefficient?  What  system  of 
underdrains  is  employed?  What  is  the  nature  of  the 
material  between  the  underdrains  and  the  sand  ?  What  is 
the  total  depth  of  the  filter?     Are  the  filters  covered? 

At  what  rate  is  the  water  filtered?  ,  How  often  is  the 
filter  cleaned?  How  is  the  necessity  for  cleaning  deter- 
mined ?  If  the  loss  of  head  is  the  determining  factor,  what 
must  this  loss  be  before  the  filter  is  cleaned  ?  What  method 
is  employed  in  cleaning  the  filter? 

How  is  the  efficiency  of  the  filter  determined?  Are 
bacteriological  tests  made  on  the  influent  and  effluent? 
Are  chemical  tests  made  on  the  influent  and  effluent? 
What  is  the  nature  of  these  tests?  How  often  are  they 
performed?  Are  they  performed  by  individuals  who  are 
properly  trained  for  this  work  ?  Are  regular  reports  of  the 
analyses  and  operation  made  public,  either  through  special 
reports  or  newspaper  articles? 


RAPID   SAND   FILTRATION 


57 


Rapid  Sand  Filtration.  —  How  many  rapid  sand  filters 
are  available?  When  were  the  earliest  built?  Have  any- 
new  units  been  added  since  then?  If  so,  how  many,  and 
when?  What  is  the  area  of  each  unit?  What  kind  of 
sand  is  employed?  What  is  the  total  depth  of  sand? 
What  is  the  effective  size  of  the  sand?  What  is  the  uni- 
formity coefficient?  What  system  of  underdrains  is  em- 
ployed? What  is  the  nature  of  the  material  between  the 
underdrains  and  the  sand?  W^hat  is  the  total  depth  of 
each  filter?     Are  the  filters  covered? 


Fig.  5.  Rapid  sand  filters  in  operation  at  Tulsa,  Okla.  Each  filter 
unit  is  Y^  of  an  acre  in  area  and  is  operated  at  the  rate  of  125,000,000 
gallons  per  acre  per  day. 

At  what  rate  is  the  water  filtered?  How  often  is  the 
filter  cleaned?  How  is  the  necessity  for  cleaning  deter- 
mined? If  the  loss  of  head  is  the  determining  factor,  what 
must  this  loss  be,  before  the  filter  is  cleaned?  What 
method  is  employed  in  cleaning  the  filter  ?  Is  air  employed 
to  free  the  dirt  from  the  sand  ?  How  long  is  the  air  allowed  to 
act  ?    How  long  is  the  reversed  flow  of  water  allowed  to  act  ? 


58  WATER-SUPPLY 

How  is  the  efficiency  of  the  filter  determined  ?  Are 
bacteriological  tests  made  on  the  influent  and  effluent  ? 
Are  chemical  tests  made  on  the  influent  and  effluent  ? 
What  is  the  nature  of  these  tests  ?  How  often  are  they 
performed  ?  Are  they  performed  by  individuals  who  are 
properly  trained  for  this  work  ?  Are  regular  reports  of  the 
analyses  and  operation  made  public,  either  through  special 
reports  or  newspaper  articles  ?  If  so,  copies  of  the  results 
should  be  obtained  and  included  in  the  report  on  the 
water-supply. 

Disinfection.  —  What  method  of  disinfection  is  em- 
ployed? When  was  disinfection  first  introduced?  It 
would  be  advisable  here  for  the  surveyor  to  show,  if  he  can, 
what  effect  water-purification,  either  by  filtration  or  disin- 
fection or  both,  has  had  on  the  typhoid  death-race  of  the 
community.  In  doing  this,  it  is  important  to  quote  the 
specific  death  rates  for  typhoid  fever,  for  at  least  several 
years  prior  to  and  after  the  introduction  of  water- 
purification. 

If  chlorine  gas  is  used,  how  is  it  applied  ?  If  hypochlorite 
is  used,  how  is  it  applied  and  what  precautions  are  taken 
to  prevent  the  sludge  from  entering  the  water-supply? 

Where  is  the  disinfectant  added  ?  Is  it  added  at  that 
point  in  the  process  where  it  will  be  most  efficient  ?  If  the 
disinfectant  is  not  added  directly  to  the  water  in  the  main, 
how  long  is  the  disinfectant  allowed  to  act  on  the  water 
before  the  water  is  used  ?  How  soon  does  the  germicidal 
effect  on  the  water  disappear  in  such  a  case  ?  What  amount 
of  chlorine,  in  parts  per  million,  is  used  for  disinfection  ? 

How  is  the  efficiency  of  disinfection  determined  ?  Are 
regular  bacteriological  tests  made  to  determine  the  efficiency 
of  disinfection  ?  Are  chemical  tests  made  to  determine 
whether  the  amount  of  chlorine  added  will  produce  an  un- 
desirable taste  in  the  water  ?  If  any  tests  are  made,  copies 
of  the  results  should  be  obtained  and  included  in  the  report 


FILTERED   WATER   BASIN   OR  STORAGE 


59 


on  the  water-supply.  Is  the  water  disinfected  throughout 
the  entire  year?  If  not,  during  what  months  of  the  year 
is  disinfection  practised? 


Fig.  6.    Liquid  chlorine  tanks  in  operation  at  Tulsa,  Okla. 
amount  of  liquid  chlorine  used  for  disinfection  was  0.2  P.P.M. 


The 


Filtered  Water  Basin  or  Storage.  —  Is  a  filtered  water 
basin  or  storage  reservoir  used  to  receive  the  water  before 
it  enters  the  mains  leading  to  the  city?  If  so,  what  are 
the  dimensions?  What  is  the  capacity,  in  gallons,  of  the 
filtered  water  basin  or  storage  reservoir?  Assuming  a 
normal  daily  consumption,  how  long  would  the  water  on 
hand  last,  if  no  fresh  supply  were  added?     What  is  the 


60 


WATER-SUPPLY 


theoretical  period  of  storage  provided  by  the  filtered  water 
l)asin  or  reservoir  ?  Where  are  the  inlet  and  outlet  located  ? 
Are  they  arranged  in  such  a  way  as  to  yield  the  maximum 
period  of  storage? 

Are  bacteriological  or  chemical  tests  made  on  the  water 
before  it  enters  the  mains?  If  so,  what  is  the  nature  of 
these  tests?  How  often  are  they  performed?  Are  they 
conducted  by  individuals  who  are  properly  trained  for 
this  work?_  Are  previous  reports  of  these  analyses  avail- 


FiG.  7.  Sedimentation  basin  with  pumping  station  in  the  back- 
ground. The  basin  is  divided  into  two  portions.  At  the  time  of  in- 
spection, the  water  was  being  short-circuited  from  inlet  to  outlet. 
This  practice  is  undesirable. 


able  in  any  form?     If  so,  copies  of  the  results  should  be 
obtained  and  included  in  the  report  on  the  water-supply. 

Tastes  and  Odors.  —  Are  tastes  and  odors  in  the  water 
observed  during  any  period  of  the  year?  If  so,  when  does 
this  period  occur?  How  long  does  it  last?  Is  the  odor 
due  to  a  growth  of  alga3?  If  not,  to  what  is  it  due? 
Describe  the  cause  in  detail. 


SPECIAL   DRINKING-WATER   SUPPLIES 


61 


If  tastes  and  odors  are  due  to  algae,  has  any  attempt 
been  made  to  free  the. water  from  them?  If  so,  what  has 
beerj  done?  Has  copper  sulphate  been  used?  If  so,  in 
what  proportions  has  it  been  applied?  In  what  manner 
has  it  been  applied?     Has  it  proved  efficient?     Has  aera- 


FiG.  8.  Open  reservoir  at  Enid,  Okla.,  where  the  water  was  dosed 
with  copper  sulphate  during  the  summer  to  destroy  the  algae.  A  solu- 
tion of  hypochlorite  of  lime  was  also  used  to  disinfect  the  water. 

tion  been  employed  to  free  the  water  from  tastes  and 
odors  ?  If  so,  by  what  method  has  the  water  been  aerated  ? 
Has  this  method  proved  efficient? 


Other  Communal  Supplies 

Special  Drinking- Water  Supplies.  —  In  most  cities  hav- 
ing a  pul)lic  water-supply,  the  practice  of  buying  a  special 
supply  of  water  for  drinking  purposes  is  confined  to  a  com- 
paratively small  section  of  the  population.  Yet  it  is  true 
that  in  some  communities  the  amount  of  drinking  water 
that  is  sold  in  bottles  or  barrels  is  exceedingly  large.     This 


02  WATER-SUPPLY 

was  found  to  be  the  case  in  all  the  important  cities  in 
Oklahoma.  In  some  of  these  cities,  hundreds  of  thou- 
sands of  dollars  are  spent  annually  for  this  special  supply 
of  drinking  water.  It  was  often  found  that  over  25  per 
cent  of  the  population  depended  for  their  drinking  water 
on  these  special  sources  of  supply. 

These  unusual  conditions  were  due  either  to  the  turbidity 


Fig.  9.  Tin  containers  used  for  delivering  well-water  in  Bartlesville, 
Okla.  The  containers  were  filled  with  water  from  the  tank,  after  it 
was  passed  through  a  patent  filter. 

or  saltiness  of  the  pu})lic  water-supply  or  to  a  popular  belief 
that  it  was  not  safe.  As  a  result  private  organizations 
were  formed  to  supply  the  residents,  the  restaurants  and 
the  hotels  with  water  obtained  from  deep  wells.  The 
water  was  delivered  to  the  residents  in  5-gallon  bottles, 
and  to  the  hotels  and  restaurants  in  large  tin  containers. 
The  charge  to  residents  was  usually  SO. 25  per  5-gallon  bottle. 
Danger  from  Other  Communal  Supplies.  —  Because  of 
these  unusual  circumstances,  the  public  schools  were  not 
furnished  with  the  public  water-supply  for  drinking  pur- 


DANGER  FROM   OTHER  COMMUNAL  SUPPLIES       63 

poses.  As  a  result,  bubbling  fountains  were  usually  absent 
from  the  schools,  and,  in  their  place,  there  were  a  variety 
of  methods  for  dispensing  drinking  water,  most  of  which 
served  as  excellent  means  for  transmitting  disease. 


Fig.  10.  A  serious  public  health  menace  in  some  schools.  An  in- 
adequate number  of  drinking  cups  in  use  by  a  large  class.  The  use 
of  the  common  drinking  cup  is  an  easy  way  to  transmit  disease. 

In  addition,  it  was  found  that  the  methods  of  washing 
and  handling  the  bottles,  corks  and  other  materials  used 
in  the  delivery  of  the  water  were  so  unsatisfactory  from  a 
sanitary  standpoint,  that  often  a  perfectly  pure  well- 
water  was  seriously  polluted  after  it  was  put  into  the  bottle. 

Moreover,  it  was  found  that  the  sale  of  this  water  was 
not  governed  by  any  regulations  or  supervision.  Wells 
were  not  examined  as  to  their  safety;  well-sites  were  not 
inspected  to  observe  whether  they  were  subject  to  pollu- 
tion. There  were  no  regulations  regarding  the  steriliza- 
tion of  bottles,  corks  and  hands.  The  men  en:iployed  in 
handling  the  water  were  not  examined  to  determine  whether 
they  were  free  from  disease. 


64 


WATER-SUPPLY 


In  some  of  the  cities  in  Oklahoma,  it  was  customary  for 
large  water-wagons  to  pass  from  house  to  house,  in  order 
to  fill  the  open  barrels  which  the  residents  provided,  and 
which  were  used  as  drinking-water  containers.  In  these 
cases,  the  houses  were  not  connected  to  the  public  mains, 
and  no  other  source  of  water  was  available.  The  water 
was  pumped  from  private  wells  into  these  water-wagons 
and  then  sold  to  the  people. 


Fig.  11.  A  water-wagon  being  filled  with  well  water.  This  water 
is  later  sold  to  the  people  and  is  stored  in  open  barrels.  Such  water 
frequently  becomes  polluted  and  serves  as  an  excellent  breeding-place 
for  mosquitoes. 


The  barrels  used  to  receive  the  water  were  open,  and 
were  thus  exposed  to  large  quantities  of  dust.  The  water 
in -them  was  frequently  polluted  by  the  hands,  and  also 
by  the  pails  used  for  dipping  out  the  water.  As  these 
barrels  were  rarely  cleaned,  the  water  in  them  was  fre- 


INSPECTION  OF  OTHER  COMMUNAL  SOURCES      65 

quently  found  to  be  unfit  for  drinking.  In  addition,  the 
open  barrels  served  as  excellent  breeding-places  for 
mosquitoes. 

For  all  these  reasons,  it  is  obvious  that  the  supplementary 
sources  of  communal  water-supply  may  have  a  direct  and 
important  effect  on  the  public  health,  and  that  these 
sources  of  drinking  water  if  they  exist  in  the  community 
under  consideration,  should  be  studied  just  as  thoroughly, 
during  the  survey,  as  the  public  supply. 

The  following  questions  will  bring  out  most  of  the  im- 
portant facts  which  the  surveyor  will  desire  to  know  regard- 
ing these  other  communal  sources  of  drinking  water. 

Inspection  of  Other  Communal  Sources  of  Drinking 
Water.  —  What  is  the  source  of  supply  ?  When  was  the 
source  inspected?  What  is  the  name  of  the  company 
supplying  the  water  ?  What  is  the  address  of  the  company  ? 
If  a  source  is  a  well,  what  is  the  depth  of  the  well  ?  What 
is  the  daily  output  in  gallons  ? 

How  many  customers  are  served  with  the  water?  What 
is  the  price  per  5-gallon  bottle?  What  is  the  price  per 
other  container? 

How  many  employees  handle  and  distribute  the  water? 
Are  the  employees  given  a  physical  examination?  By 
whom?  What  is  the  nature  of  the  examination?  How 
often  is  the  examination  conducted?  Are  records  avail- 
able to  show  that  each  employee  has  been  examined? 

Is  the  well  protected  against  surface  pollution  ?  Describe 
the  method  of  protection  employed.  How  is  the  water 
obtained  from  the  well  —  by  pump  or  by  hand  ?  Are 
there  sources  of  pollution,  such  as  open  privies,  hog-pens, 
manure-piles,  exposed  garbage  and  similar  organic  refuse 
in  the  immediate  vicinity?  Is  the  slope  of  the  ground  in 
such  cases  towards  the  well? 

Are  satisfactory  toilet  facilities  available  for  employees? 
Are  satisfactory  washing  facilities  available  for  them? 


66  WATER-SUPPLY 

Are  the  bottles  washed  with  fresh,  clean  water? 
Describe  the  method  employed  for  washing  bottles.  Is  a 
brush  used  in  washing  the  bottles?  Are  any  chemicals 
used  in  washing  the  bottles?  If  so,  what  are  they?  Are 
the  bottles  thoroughly  rinsed  in  pure  water?  Are  they 
steriUzed?     If  so,  describe  the  method  employed. 

Is  the  well-water  treated  in  any  way?  If  so,  describe 
the  treatment  employed. 

Are  bottles  filled  mechanically?  Are  the  cork  stoppers 
sterilized  before  being  reused  ?  If  so,  what  is  the  method 
employed?  Is  waxed  paper  used  between  the  cork  and 
the  bottle?  Are  the  stoppered  bottles  further  protected 
by  means  of  dust-proof  paper  caps? 

How  often  are  the  premises  inspected  ?  Who  performs 
the  inspection?     When  was  the  last  inspection  made? 

Are  analyses  of  the  water  regularly  made?  If  so,  by 
whom?  What  is  the  nature  of  these  analyses?  When 
was  the  last  analysis  made?  Are  the  results  of  these 
analyses  available?  If  they  are,  the  surveyor  should 
obtain  copies  of  them,  to  be  included  in  the  final  report. 

Is  the  sale  of  this  water  regulated  by  local  ordinance? 
Is  the  sanitary  quality  of  the  water  regulated  by  local 
ordinance  ? 

Private  Water-Supplies 

In  almost  every  community,  which  is  not  a  large  metro- 
politan center,  a  considerable  portion  of  the  people  depend 
on  private  sources  of  water-supply,  either  for  drinking  pur- 
poses alone,  or  for  all  the  domestic  needs.  The  private 
sources  of  water-supply  are  usually  wells,  cisterns  or  springs. 
The  number  of  wells  and  cisterns  will  depend  on  the  size 
of  the  community,  the  wealth  of  the  people,  the  purity  and 
quality  of  the  public  water-supply,  and  the  extent  to  which 
it  serves  the  city. 


PRIVATE   WATER-SUPPLIES 


67 


Where  private  supplies  are  in  use,  and  where  the  public 
water-supply  is  hard,  turbid  or  of  doubtful  safety,  the 
more  wealthy  residents  usually  have  excellent  cisterns, 
which  are  thoroughly  covered,  and  protected  from  pollution. 
The  water  obtained  from  these  cisterns  is  soft  and  cold. 
In  samples  taken  from  them  in  Bartlesville,  Oklahoma,  the 
author  found  less  than  10  bacteria  per  c.c.  and  no  B.  coli 
in  10  c.c.  amounts.  Such  water  is  usually  good.  There  are, 
however,  other  residents  who  collect  the  rainwater  in  open 
barrels,  frequently  not  only  polluted,  but  uncovered,  so 
that  they  are  excellent  breeding-places  for  mosquitoes. 


Fig.  12.  A  barrel  used  to  collect  rain  water,  in  which  mosquitoes 
were  actively  breeding. 

Wells  are  either  shallow  or  deep.  A  shallow  well  is  one 
in  which  the  depth  from  the  surface  of  the  ground  to  the 
level  of  the  water  is  less  than  30  feet.  Where  the  depth 
is  greater  than  30  feet,  the  well  is  usually  considered  a 
deep  one.  Wells  are  very  frequently  insufficiently  pro- 
tected at  the  surface,  so  that  the  washings  from  privies, 
manure-piles,    hog-pens,    exposed    garbage,    chicken-yards 


68 


WATER-SUPPLY 


and  other  sources  of  pollution  find  their  way  into  them. 
This  is  particularly  true  if  the  ^I'ound  slopes  toward  the  well. 
Since  wells  and  cisterns  may  serve  as  sources  of  drinking 
water  for  a  large  section  of  the  population,  it  is  important 
to  inspect  all  of  these  private  sources  of  supply.  Where 
this  is  not  possible,  the  surveyor  should  inspect  the  private 
sources  of  supply  in  the  poorer  sections  of  the  city  particu- 


FiG.  13.  A  row  of  tottering  shacks  in  a  large  city  where  some  very 
poor  housing  conditions  prevail.  Note  the  privy  in  the  rear.  The 
pump  in  the  foreground  supplied  twenty  families  in  the  neighborhood 
with  water.     The  ground  slopes  from  the  privy  to  the  well. 

larly,  as  these  are  more  apt  to  be  polluted  than  the  wells 
and  cisterns  in  the  better  portions  of  the  city.  If  it  is 
possible  to  inspect  some  of  the  private  sources  of  supply 
in  each  district,  the  results  will  doubtless  be  more  represen- 
tative of  the  whole  city,  than  those  obtained  by  an  inspec- 
tion of  one  district  alone. 

Wherever  possible,  it  is  desirable  to  locate  each  well  and 
cistern  and  to  plot  these  on  a  map,  divided  according  to 
districts.  Later  on,  the  surveyor  can  compare  the  distri- 
bution of  wells  and  cisterns  together  with  that  of  open 


WELLS 


69 


privies,  plotted  in  the  same  way,  with  the  prevalence  of 
typhoid  fever,  other  intestinal  diseases  and  infant  mortality, 
in  each  district.  Sometimes  an  important  and  striking  re- 
lationship can  be  demonstrated  in  this  way.  Even  if  such 
a  relationship  does  not  exist,  it  is  exceedingly  interesting 
to  show,  in  a  graphic  way,  the  number  and  distribution  of 
wells,  cisterns  and  open  privies  in  a  community. 

The  following  questions  aim  to  bring  out  the  important 
information  about  the  private  sources  of  water-supply. 

Wells.  —  How  deep  is  the  well  ?  What  kind  of  a  well 
is  it?     Is  it  protected  against  surface  pollution?     If  so, 


Fig  14.  Location  of  stable,  manure-pile  and  well  within  close 
proximity  to  each  other.  Under  such  conditions,  the  well-water  is 
almost  always  seriously  polluted. 

what  is  the  nature  of  this  protection?  Is  the  water  re- 
moved by  pumping?  What  kind  of  device  is  employed 
to  lift  the  water  from  the  well?  How  many  people  are 
dependent  on  this  source  of  supply?  What  is  the  distance 
from  the  well  to  the  nearest  house? 

Are  there   any  sources  of  pollution  in  the  immediate 


70  WATER-SUPPLY 

vicinity,  such  as  an  open  privy,  manure-pile,  hog-pen  or 
chicken-yard?  What  is  the  distance  from  these  sources 
of  pollution  to  the  well?  Does  the  ground  slope  toward 
the  well  from  the  sources  of  pollution?  If  not,  is  the 
danger  of  pollution  still  real? 

Is  the  well  ever  inspected?  If  so,  how  often,  and  by 
whom?  Is  the  well-water  ever  analyzed?  If  so,  how 
often,  and  by  whom?  Are  the  results  of  any  previous 
analyses  available?  If  they  are,  the  surveyor  should 
obtain  copies  of  them  for  the  final  report.  Does  any  local 
ordinance  govern  the  use  and  specify  the  supervision  of 
the  wells?     If  so,  what  are  these  regulations? 

Cisterns.  —  What  are  the  dimensions  of  the  cistern  ? 
What  is  its  capacity?  During  what  periods  of  the  year 
is  it  allowed  to  fill?  Ascertain  the  facts  regarding  the 
cleaning  of  the  cistern  and  whether  or  not  the  first  wash- 
ings of  the  roof  are  discarded.  Is  the  cistern  closed, 
screened  or  open?     If  open,  are  mosquito  larvae  present? 

Is  the  cistern  ever  inspected?  If  so,  how  often,  and  by 
whom?  Is  the  cistern-water  ever  analyzed?  If  so,  how 
often,  and  by  whom?  Are  the  results  of  any  of  these 
analyses  available?  If  they  are,  the  surveyor  should 
obtain  copies  of  them  and  include  them  in  the  final  report. 

Is  the  use  of  cisterns  governed  by  any  local  ordinance? 
If  so,  does  the  ordinance  require  the  supervision  of  the 
cisterns?  The  surveyor  should  acquaint  himself  with  all 
the  regulations  pertaining  thereto,  and  determine  the 
extent  to  which  they  are  enforced. 

Laboratory  Analyses  of  All  Sources  of  Drinking  Water. 
—  Not  only  is  it  important  for  the  surveyor  to  make 
thorough  inspections  of  the  public  water-works  and  other 
communal  sources  of  supply,  and  also  the  \Yells  and  cis- 
terns, but  it  is  equally  important  to  collect  samples  of 
water  from  each  source,  and  to  examine  these  waters 
thoroughly.     Wherever  possible,   a  complete  chemical  as 


LABORATORY  ANALYSES  71 

well  as  a  bacteriological  analysis  should  be  made.  Some- 
times, however,  the  facilities  for  making  a  complete  chemi- 
cal  analysis  are  not  available,  or  possibly  the  time  of  the 
surveyor  is  so  limited,  and  his  help  so  meagre,  that  it  will 
be  impossible  to  make  a  chemical  analysis  of  each  water. 

When  facilities  for  making  such  an  analysis  are  not 
locally  available,  it  is  often  possible  to  arrange  with  the 
state  health  department  laboratories  to  have  the  analyses 
performed  there,  if  the  waters  are  brought  to  the  labora- 
tory by  messenger  or  express.  In  any  case,  it  is  desirable 
to  find  some  method  whereby  the  public  water-supply  may 
be  chemically  examined.  If  the  chemical  examination  of 
any  water  is  to  be  omitted,  it  is  preferable  to  omit  the 
analyses  of  the  supplementary  communal  supplies  and  the 
private  water-supplies. 

In  no  case,  however,  is  it  desirable  to  omit  the  bac- 
teriological analyses.  Containers  for  taking  samples  for 
the  chemical  and  bacteriological  analyses  can  usually  be 
borrowed  from  the  local  health  department  laboratory,  if 
one  exists,  or  from  the  state  health  department  laboratory. 
Some  provision  should  be  made  for  icing  the  bacteriological 
samples  between  the  period  of  collection  and  analysis.  It 
is  needless  to  say,  of  course,  that  the  containers  used  for 
collecting  samples  of  water  for  bacteriological  analysis 
should  be  clean  and  sterile,  and  that  the  water  should 
receive  no  external  contamination  of  any  sort,  after  the 
sample  is  collected. 

It  is  important,  too,  that  the  sample  of  water  should  be 
truly  representative  of  its  source,  and  that  it  should  be 
collected  with  extreme  care,  to  avoid  introducing  foreign 
bacteria.  Not  only  should  the  sample  be  iced  immediately 
and  kept  cold  until  analyzed,  but  the  analysis  should 
furthermore  be  performed  as  soon  after  the  time  of  collection 
as  possible..  In  spite  of  the  fact  that  the  sample  is  being 
iced,  it  should  be  analyzed  within  six  hours  after  collection. 


72  WATER-SUPPLY 

The  author  has  found  it  very  advantageous  to  collect 
all  the  bacteriological  samples  personally,  and  also  to 
make  the  actual  examinations.  Unless  the  surveyor  is 
aided  by  somebody  who  is  adequately  trained  for  such 
work,  and  in  whose  integrity  he  has  absolute  faith,  it  would 
be  better  to  perform  the  bacteriological  examinations  alone. 
Very  often  it  is  an  easy  matter  to  arrange  with  the  local  or 
the  state  health  department  laboratory  for  the  examina- 
tion of  the  samples.  It  is  better,  however,  for  the  sur- 
veyor not  to  seek  this  aid,  in  order  that  he  may  be  certain 
of  the  correctness  of  the  results. 

In.  many  small  communities  a  health  department  labora- 
tory will  not  be  available.  Usually,  however,  laboratory 
facilities  of  some  kind  will  be  found.  Such  facilities  may 
exist  in  the  private  laboratories  of  physicians,  hospitals, 
industrial  organizations  or  high  schools.  It  is  usually  not 
difficult  to  arrange  for  the  use  of  these  laboratories,  if  they 
can  be  found.  If  the  private  laboratory  facilities  are  ac- 
cepted by  the  surveyor,  it  is  important  that  he  furnish  his 
own  materials,  as  far  as  possible.  By  doing  so  he  will 
inconvenience  his  host  to  the  smallest  possible  degree,  and 
will  make  his  presence  less  undesirable.  He  can,  of  course, 
arrange  to  use  the  incubator,  sterilizers,  sink,  burners,  and 
other  similar  staple  things;  but  the  media,  pipettes,  test 
tubes,  dilution  waters,  and  other  materials  which  might 
break  or  be  used  up,  ought  to  be  supplied  by  the  surveyor. 

Very  often,  the  surveyor  may  not  have  any  assistants, 
and  it  may  be  necessary  for  him,  therefore,  to  wash  the 
test-tubes  and  dishes,  to  prepare  the  media,  to  operate  the 
sterilizers,  and,  besides  collecting  the  samples,  to  perform 
the  analyses  and  to  interpret  the  results. 

It  is  needless  to  say  that,  in  a  bacteriological  examina- 
tion, only  sterile  materials  should  come  into  contact  with 
the  water  that  is  to  be  analyzed. 

When  everything  is  ready  for  the  analyses,  the  surveyor 


LABORATORY  ANALYSES  73 

should  collect  the  samples  of  the  public  water-supply,  the 
other  communal  supplies,  and  the  private  supplies. 

In  obtaining  samples  from  the  public  supply,  it  is  de- 
sirable to  collect  the  samples  from  various  faucets  in  differ- 
ent parts  of  the  city.  The  time  between  the  collection  of 
these  samples  should  be  as  short  as  possible.  The  water 
from  the  tap  should  be  allowed  to  flow  for  about  five 
minutes  before  the  sample  is  taken,  as  it  should  be  a 
sample  of  the  water  which  is  actually  in  the  street  main. 

Samples  of  a  bottled  water-supply  should  preferably  be 
obtained  from  two  places.  One  should  come  directly  from 
the  original  source,  such  as  the  well  or  spring,  and  the 
other  from  the  final  container.  In  the  latter  case,  the 
final  container  should  preferably  have  been  filled  immedi- 
ately before  sampling,  and  should  be  thoroughly  shaken 
before  the  sample  is  obtained.  Care  must  also  be  taken 
not  to  contaminate  the  mouth  of  the  container  from  which 
the  water  is  removed,  as  this  would  be  very  likely  to 
increase  the  bacterial  count  unjustly.  By  taking  these 
precautions,  and  by  obtaining  samples  both  from  the 
source  and  from  the  bottle,  it  is  possible  to  determine  the 
purity  of  the  water  at  its  source,  as  well  as  that  of  the 
water  in  the  final  container.  As  these  waters  are  fre- 
quently pure  at  their  source,  but  are  polluted  by  improper 
handling  or  dirty  containers,  the  importance  of  this  pre- 
caution is  obvious. 

Samples  should  aho  be  taken  from  private  wells  and 
cisterns  in  every  part  of  the  city,  and  analyzed  with  the 
others.  If  the  number  of  wells  and  cisterns  is  large,  so 
that  it  is  impos-sibb  to  examine  all,  it  is  permissible  to 
examine  only  those  in  the  poorer  districts. 

It  is  obvious  that  the  testimony  of  one  examination 
alone  cannot  usually  be  considered  sufficient  to  condemn 
a  water-supply,  particularly  a  public  one.  It  is  therefore 
desirable  to  make  daily  tests  on  the  pubhc  supply  for  at 


74 


WATER-SUPPLY 


least  a  week  and  perhaps  even  longer,  before  attempting 
to  determine  the  condition  of  the  water.  This  does  not 
mean  that  the  chemical  examination  must  be  repeated 
every  day;  usually  one  chemical  examination  suffices  for 
most  waters.  But  the  bacteriological  examination  should 
be  performed  daily  for  at  least  a  week. 

The    following    forms    may  prove  helpful  in  recording 
the  results  of  the  analyses  for  the  final  report. 

TABLE   1 
ANALYSIS    OF   "CITY   A"   WATER* 


Faucet  in  district  number. 

(1) 

(2) 

(3) 

(4) 

Albuminoid  Ammonia 
Free  Ammonia 
Nitrogen  as  Nitrates 
Nitrogen  as  Nitrites 
Chlorine 
Total  Solids 
Alkalinity 
Oxygen  Consumed 

Results  in  parts  per  million. 


Bacteriological  Tests 
Bacteria    per    c.c.  on 

Agar  after  24  hours 

at  37°  C. 
Per  cent    of    Gas    in 

Lactose  Broth  after 

21  hours  at  37°  C... 


.1  c.c. 

5  c.c. 

10  c.c. 


Interpretation 

Use    safe,    suspi- 
cious, unsafe) 


EXAMINATION  OF  OTHER  SOURCES 


75 


TABLE   2 

EXAMINATION   OF   OTHER   COMMUNAL   SOURCES   OF 

DRINKING   WATER 

Samples  Taken  from  Bottles 


Name  of  company  supplying  water. 

Chemical  tests  in  parts  per  million. 

A 

B 

C 

D 

Albuminoid  Ammonia 
Free  Ammonia 
Nitrogen  as  Nitrates 
Nitroten  as  Nitrites 
Chlorine 
Total  Solids 
Alkalinity 
Oxygen  Consumed 

Bacteriological  Tests 
Bacteria  per  c.c.  on 
Agar  after  24  hours 
at  37°  C. 
Percentage    Gas    in 
Lactose  Broth  after 
24  hours  at  37°  C.  ..Ic.c. 

5c. c. 
10  c.c. 

Interpretation 


Samples  Taken  from  Original  Source  (Wells,  etc.) 

Bacteriological  Tests 
Bacteria  per  c.c.  on 
Agar  after  24  hours 
at  37°  C. 
Percentage    Gas    in 
Lactose  Broth  after 
24  hours  at  37°  C.  ..Ice. 

5c. c. 
lOc.c. 

Interpretation 


76 


WATER-SUPPLY 


TABLE  3 

EXAMINATION   OF   PRIVATE   SOURCES   OF   DRINKING 

WATER 


Location  of 
source. 

Nature  oi 
source. 

Bacteria  per 

c.c.  on  agar 

after  24  hours 

at37°C. 

Percentage  gas  in 
lactose  broth  after 
24  hours  at  37°  C. 

Interpre- 
tation. 

1  c.c. 

5  c.c. 

10  c.c. 

Date  of  Examination. 


OUTLINE   OF   CHAPTER   ON   WATER-SUPPLY 

In  order  to  aid  the  surveyor  in  preparing  his  report  on 
the  water-supply  of  the  community,  the  following  outline 
is  inserted.  It  enumerates  most  of  the  factors  which  he 
will  want  to  consider,  and  arranges  the  main  headings  in  a 
manner  which  is  regarded  as  satisfactory.  It  will  also  aid 
the  surveyor  in  avoiding  omissions,  when  he  is  confronted 
by  a  mass  of  data  as  he  begins  to  write  his  report. 

1.  Brief  introduction  dealing  with  the  importance  of  a  pure  and 
adequate  municipal  water-supply,  and  its  relation  to  the  public  health 
and  comfort. 

2.  History  of  the  water-supply,  including  a  r^sum^  of  previous  in- 
vestigations, studies,  recommendations. 


OUTLINE  OF  CHAPTER  ON   WATER-SUPPLY         77 

3.  Description  of  source;  method  of  treatment,  nature  of  supply; 
dimensions  of  basins,  filters,  etc.;  capacity  of  basins,  reservoirs,  etc.; 
size  of  pipes  in  use;  size  of  reservoirs  for  reserve  supply;  P.P.M.  of 
chemicals  used;  operation  of  the  plant;  frequency  of  cleaning  the 
basins,  the  filters,  etc.;  precautions  against  an  interruption  of  the 
supply;  pressure;  quantity  used,  in  gallons  per  day,  and  in  gallons  per 
capita  per  da^/;  number  of  meters  in  use;   cost  of  water. 

4.  Other  communal  supplies. 

Number  of  wells  selling  water;  amount  of  water  sold;  cost  of 
watei  per  given  unit  of  volume  for  different  consumers;  total  cost; 
depth  of  wells;  results  of  sanitary  inspections  of  well-sites;  methods  of 
treating  the  water;  methods  employed  in  washing  bottles;  steriliza- 
tion of  bottles;  use  of  corks;  use  of  waxed  paper  between  cork  and 
mouth  of  bottle;  use  of  paper  caps. 

5.  Private  supplies. 

Wells  in  use;  sanitary  inspection  of  wells  and  cisterns  in  use;  pre- 
vious analyses  of  water-supplies;  collection  of  samples  for  analysis; 
analyses. 

6.  Chemical  and  bacteriological  analyses  of  the  public  supply,  well- 
waters  and  cistern-waters;  interpretation  of  analyses. 

7.  Map  of  water-supply  system;  map  showing  location  of  wells, 
cisterns;  photographs. 

8.  Extent  to  which  city  is  served  with  water;  extent  to  which  city 
is  without  pubhc  water-supply. 

9.  Peculiar  problems  —  excess  salt,  inadequate  supply,  unsafe  sup 
ply,  personnel,  laboratory  control. 

10.  Summary. 

11.  Recommendations. 


CHAPTER   VI 
DRAINAGE,    SEWERAGE    AND    SEWAGE-DISPOSAL 

Prompt  Removal  of  Sewage  an  Important  Municipal 
Function.  —  In  addition  to  furnishing  a  pure  and  adequate 
water-supply,  every  municipality  must  provide  for  the 
removal  of  wastes.  This  is  of  the  utmost  importance  as 
a  means  of  safeguarding  the  health  of  the  people.  The 
most  important  wastes  are  those  of  human  origin,  and 
those  resulting  from  the  various  processes  associated  with 
life.  These  wastes  must  be  removed  frequently  and  satis- 
factorily, in  order  to  prevent  the  spread  of  disease. 

The  wastes  of  life,  exclusive  of  expired  air,  may  be 
divided  into  two  classes,  —  those  that  are  liquid,  and  those 
that  are  solid.  The  liquid  wastes  arc  called  sewage  and 
the  solid  wastes,  refuse.  The  collection  and  disposal  of 
refuse  will  be  considered  in  the  following  chapter;  this 
chapter  considers  only  the  collection  and  disposal  of  sewage. 

The  Character  of  Sewage.  —  Sewage  has  been  defined 
as  the  used  water  of  a  community.  Any  water  which  has 
been  used  in  the  activities  of  man,  whether  it  be  grossly  or 
slightly  polluted,  is  sewage.  Sewage,  however,  contains 
solid  matter,  in  addition  to  water,  and  this  solid  matter 
consists  of  both  organic  and  inorganic  materials.  The 
liquid  portion  of  sewage  also  contains  organic  and  inor- 
ganic matter  in  solution.  It  is  the  organic  matter  in 
sewage  which  decomposes  under  proper  conditions  and 
creates  a  nuisance.  If  the  sewage  of  a  city  is  large  in 
volume,  and  is  treated  only  to  an  inadequate  degree,  and 
if  the  receiving  body  of  water  does  not  dilute  the  sewage 
adequately,   very  noisome   conditions  may  result  due  to 

78 


THE  PRIVY  79 

the  decomposition  of  the  sludge.  The  oxygen  supply  of 
the  stream  becomes  diminished,  fish  life  is  either  destroyed 
or  driven  out  of  that  locality,  and  foul  odors  usually  result, 
particularly  during  the  warm  weather. 

Polluted  Water-Supplies  Should  First  be  Purified.  — 
The  most  serious  objection  to  improperly  handled  sewage, 
however,  is  that  it  may  be  responsible  for  spreading  dis- 
ease, especially  diseases  of  intestinal  origin,  such  as  typhoid 
fever,  dysentery,  cholera,  diarrhea,  and  sometimes  hook- 
worm. Sewage  frequently  contains  the  germs  of  the  first 
four  diseases,  but  in  the  United  States,  where  cholera  is 
practically  unknown,  the  sewage  will  of  course  be  free 
from  cholera  bacilli.  If  the  sewage  is  not  adequately 
treated  before  flowing  into  water  which  is.  used  for  drinking 
purposes,  or  if  it  causes  shellfish  to  become  infected  with 
the  germs  of  typhoid  fever,  or  if  the  polluted  water  from 
the  stream  is  used  for  drinking  purposes  without  being 
filtered,  disinfected  or  boiled,  then  the  sewage  which  was 
discharged  in  it  may  be  directly  responsible  for  many 
cases  of  intestinal  disease. 

It  is  therefore  evident  that  the  proper  disposal  of  sewage 
is  important  from  the  public  health  standpoint.  Many 
American  communities,  such  as  Albany,  Pittsburgh,  Cin- 
cinnati, St.  Louis,  Niagara  Falls,  Lawrence  and  Lowell, 
have  materially  diminished  the  prevalence  of  typhoid  fever 
and  the  mortality  resulting  from  it  by  purifying  the  drink- 
ing water,  which,  in  each  case,  was  obtained  from  sewage- 
polluted  streams. 

The  Privy  is  Still  a  Very  Important  Public  Health  Prob- 
lem. —  Most  American  communities,  even  among  those  of 
great  size,  are  not  entirely  provided  with  sewers.  Larger 
or  smaller  areas,  depending  on  the  progressiveness  of  the 
citizens,  are  supplied  with  privies,  which  are  usually  exposed 
to  flies  and  are  unsanitary  in  other  ways.  The  excreta 
are  collected  infrequently  and  serious  nuisances  result. 


80         DRAINAGE,   SEWERAGE,   SEWAGE-DISPOSAL 

The  washings  from  these  privies  have  been  known  to 
pollute  wells  used  as  sources  of  drinking  water.  Sometimes 
the  poorer  sections  of  certain  cities  and  certain  backward 
rural  sections  are  not  even  supplied  with  privies,  and  the 
excreta  are  simply  deposited  on  the  ground. 


Fig.  15.  The  alley  is  often  a  place  for  refuse  of  all  sorts.  Here  is 
one  with  a  row  of  open  privies  to  which  flies  and  animals  have  easy 
access. 

Urban  dwellers  do  not  usually  realize  that  the  privy 
presents  one  of  the  most  serious  public  health  problems  of 
to-day.  It  is  serious  not  only  from  the  standpoint  of  pub- 
lic health,  but  also  from  the  standpoint  of  decency.  Who 
will  deny  to-day  that  decency  is  intimately  associated  with 
our  efforts  to  improve  the  public  health? 

More  than  half  a  century  ago,  Berlin  was  able  to  demon- 
strate not  only  that  an  improvement  in  the  water-supply 
reduces  the  death-rate  from  typhoid  fever,  but  that  the 
installation  of  a  water-carriage  system  for  the  removal  of 
human  wastes  also  diminishes  the  typhoid  fever  death- 
rate.     The  prevalence  of  open  privies  in  a  community  also 


SEWERAGE  SYSTEM 


81 


tends  to  increase  the  infant  mortality  rate,  especially  from 
diseases  of  intestinal  origin.  Moreover,  in  those  sections 
of  the  world  where  the  hookworm  is  found,  one  of  the 
means  by  which  the  disease  is  propagated  is  the  presence 
of  open  and  unsanitary  privies,  or  the  total  lack  of  facili- 
ties for  excreta  disposal. 


•r^  ■  -•'   -.- 


Fig.  16.  A  series  of  open,  foul  privies  in  a  populous  section  of  a 
large  city.     The  houses  were  only  fifty  feet  away. 

Data  can  be  Obtained  from  City  Engmeer  or  Superin- 
tendent of  Sewers.  —  The  information  pertaining  to  the 
sewerage  system,  the  extent  to  which  the  city  is  sewered  and 
the  methods  of  treatment  employed  can  be  obtained,  as  a 
rule,  from  the  city  engineer  or  the  superintendent  of  sewers. 
An  appointment  with  the  proper  official  should  be  made, 
and   the   answers   to   the   following   questions   should    be 

obtained. 

Sewerage  System.  Extent  to  which  City  is  Sewered.  — 
Is  the  sewerage  system  on  the  combined  or  on  the  sepa- 


82 


DRAINAGE,   SEWERAGE,   SEWAGE-DISPOSAL 


rate  plan?  In  either  case,  ascertain  the  size  of  each  sewer 
and  the  length  of  each  size  in  use.  Ascertain  also  the  size  of 
each  storm-sewer  in  use  and  the  length  of  each  size.  What 
is  the  slope  of  each  sewer?  What  is  the  capacity  of  the 
trunk  and  outfall  sewers? 

How  many  sanitary  sewer-outfalls  are  in  use?  Where 
is  each  located?  Into  what  body  of  water  does  each  dis- 
charge ?     What  is  the  size  of  each  sewer  at  its  outfall  ? 


Fig.  17.  A  sanitary  sewer  discharging  untreated  sewage  into  a 
shallow  stream.  Man}-  cities  have  numerous  sewer-outfalls  which  dis- 
charge untreated  sewage  and  cause  local  nuisances. 

How  many  storm-sewers  arc  available?  Where  is  each 
located?  Into  what  body  of  water  or  lot  does  each  storm- 
sewer  discharge  ?  Is  the  storm- water  or  any  portion  thereof 
treated  in  any  way?  If  so,  describe  the  method  employed. 
What  is  the  size  of  each  sewer  at  its  outfall? 

What  is  the  total  sewage-flow  per  day?     What  portion 
of  the  daily  flow  is  discharged  at  each  sewer-outfall?     Is' 
the  sewage  treated  in  any  way?     If  so,  ascertain  the  meth- 
ods employed  and  the  location  of  the  sewage  treatment 


SEWERAGE   SYSTEM  83 

plant,  and  arrange  to  visit  the  disposal  plant  later,  in  order 
to  inspect  it  and  to  get  first-hand  information  regarding 
its  construction  and  operation. 

What  portions  of  the  city  are  still  unsewered?  Is  there 
any  definite  plan  to  provide  these  sections  with  sewer 
facilities  in  the  near  future?  If  so,  when?  What  propor- 
tion of  the  population  or  of  the  homes  is  provided  with 
sewer  facilities? 

The  surveyor  should  be  able  to  obtain  this  information 
from  the  housing  survey,  if  it  cannot  be  obtained  from  the 
city  engineer  or  the  superintendent  of  sewers.  In  the 
same  way,  he  will  be  able  to  ascertain  the  number  of  privies 
in  use,  and  the  number  of  homes  which  abutt  sewers,  but 
which  are  not  connected  to  the  sewer.  In  some  cases, 
where  the  periodic  cleaning  of  privies  is  regulated  by  law, 
the  health  officer  or  some  other  city  official  under  whom 
this  work  is  done,  will  be  able  to  furnish  the  information 
regarding  the  number  of  privies  in  use.  The  information 
regarding  cesspools  may  also  be  obtained  either  through 
the  housing  survey,  or  through  a  city  official,  if  the  cess- 
pools are  regulated  like  the  privies. 

Although  the  information  regarding  privies  and  cesspools 
is  obtained  during  the  housing  survey,  the  data  may  be 
presented  in  this  chapter.  If  it  is  considered  desirable,  the 
information  may  be  recorded  in  both  places,  thus  making 
each  chapter  a  complete  entity. 

Here,  again,  the  surveyor  will  find  it  valuable  to  make 
a  spot-map  showing  the  location  of  all  the  privies  in  the 
community.  This  may  be  related  to  the  spot  map  show- 
ing the  distribution  of  wells,  and  both  may  be  studied 
in  relation  to  the  prevalence  and  distribution  of  typhoid 
fever.  The  spot-map  showing  the  privies  is  also  important 
in  demonstrating  the  possible  relationship  between  the 
location  of  privies  and  the  prevalence  of  high  infant  mor- 
tality rates. 


84 


DRAINAGE,  SEWERAGE,  SEWAGE-DISPOSAL 


The  information  brought  out  by  the  following  questions 
should  also  be  obtained. 

What  area  is  served  by  the  sewerage  system?  What 
proportion  of  the  total  area  of  the  community  is  served 
by  the  sewerage  system?  Does  the  disposal  of  the  sewage 
present  any  special  problem,  such  as  that  created  by  the 


Fig.     18.      Another  type  of  open  privy  which  hardly  affords  privacy. 

wastes  of  tanneries,  slaughter-houses,  large  dairies,  oil- 
refineries,  gas-works,  sugar-refineries,  breweries,  bleach- 
eries,  wool-scouring  plants  chemical  plants  or  any  other 
industrial  enterprise  ? 

Previous  Reports  should  be  Obtained  and  Carefully 
Studied.  —  The  surveyor  should  obtain  copies  of  previous 
reports  on  the  problem  of  collection  and  disposal  of  sewage 
in  the  community.  These  reports  should  be  obtained,  if 
possible,  before  the  interview  with  the  city  engineer  or 
superintendent  of  sewers.  In  that  case,  the  surveyor 
should  acquaint  himself  with  these  previous  studies  in 
order  that  he  may  be  able  to  discuss  the  existing  situation 
and  its  problems  more  intelligently.     Those  portions  of  the 


SEWER-OUTFALLS  SHOULD   BE  VISITED  85 

previous   reports   which   seem   to   be   of   particular   value 
should  be  included  in  the  report  made  by  the  surveyor. 

Map  of  Sewerage  System  should  be  Obtained.  —  At  the 
interview  with  the  city  engineer  or  superintendent  of  sewers, 
the  surveyor  should  arrange  to  obtain  a  map  of  the  city 
showing  the  extent  and  plan  of  the  sewerage  system.  Some- 
times these  maps  are  not  up-to-date.  In  that  case  the 
surveyor  must  determine  what  the  value  of  the  map  will  be 
to  him.  In  other  cases,  there  will  be  only  one  copy  of  the 
map  available.  In  such  a  contingency,  it  is  usually  pos- 
sible to  have  a  special  copy  made  for  the  report. 

Supervision  of  Sewage-Treatment  Plant.  —  Where  a 
sewage-disposal  plant  is  in  operation,  the  surveyor  should 
ascertain  whether  the  superintendent  is  trained  for  the 
work,  and  whether  regular  laboratory  tests  are  made  to 
control  the  operation  of  the  plant.  If  these  tests  are  being 
made  regularly,  it  is  desirable  to  obtain  copies  of  the  results 
for  the  final  report.  These  results  should  be  analyzed 
and  discussed  by  the  surveyor. 

Sewer-Outfalls  should  be  Visited.  —  After  the  interview 
with  the  city  engineer  or  superintendent  of  sewers,  the  sur- 
veyor should  arrange  to  have  somebody  take  him  to  each 
of  the  sewer-outfalls.  The  person  who  acts  as  his  guide 
should  be  acquainted  with  the  location  of  each  outfall,  as 
much  time  and  energy  will  be  saved  in  that  way.  It  is 
particularly  important  to  note  the  character  and  volume 
of  sewage  at  each,  outfall,  and  whether  any  obvious  nuisance 
or  danger  to  health  exists.  The  amount  of  dilution  which 
the  sewage  gets  after  it  is  discharged  should  also  be  noted. 

When  the  outfalls  have  been  inspected,  the  surveyor 
may  turn  to  the  sewage-treatment  plant.  Numerous  pro- 
cesses are  employed  in  the  treatment  of  sewage.  The 
most  important  are  hsted  below,  together  with  questions 
calculated  to  bring  out  the  necessary  information  concern- 
ing them. 


.\ 


i 


J^»^ 


l-'iG.  19.  A  stonij-riewer  discharging  drainage  during  dry  weather.. 
During  the  early  part  of  a  storm,  the  volume  of  sewage  is  much  greater 
and  is  often  concentrated.  (86) 


FINE  SCREENS  87 

Sewage-Disposal  by  Dilution.  —  In  many  cases  the  sew- 
age is  discharged,  without  any  treatment,  into  the  nearest 
stream,  while  in  other  cases  it  is  subjected  to  preUminary 
treatment.  It  is  important,  in  either  case,  to  determine 
whether  any  nuisance  or  menace  to  the  pubUc  health 
exists.     Thus  the  following  questions  should  be  answered. 

Into  what  body  of  water  does  the  sewage  finally  dis- 
charge? What  dilution  does  it  receive?  Does  the  sewage 
enter  a  stream  which  is  later  used  by  another  community 
as  a  source  of  water-supply?  If  so,  what  is  the  name  and 
population  of  this  city,  and  how  far  downstream  is  it 
located?  The  surveyor  should  determine  whether  that 
city  purifies  its  water  and  whether  the  typhoid  death-rate 
in  that  community  is  high.  Does  the  sewage  pollute  any 
shellfish,  or  bathing  beaches,  or  cause  any  other  serious 
nuisance  or  menace  to  the  public  health?  If  so,  describe 
in  detail. 

Have  sludge-banks  formed  at  the  point  of  outfall?  Are 
they  offensive?  Obtain  and  record  any  chemical  and  bac- 
teriological data  that  are  available. 

Coarse  Screens.  —  Are  the  coarse  screens  made  of  par- 
allel iron  bars  or  are  they  built  in  the  form  of  cage-screens  ? 
Are  the  screens  placed  so  that  they  are  perpendicular  to 
the  line  of  flow?  If  not,  what  is  the  angle  of  inclination? 
How  many  coarse  screens  are  in  use?  Of  what  material 
are  the  screens  constructed?  What  is  the  size  of  each 
opening  ? 

Are  the  screens  so  arranged  that  they  act  in  series? 
How  often  are  they  cleaned?  What  method  of  cleaning 
is  employed?  How  much  screenings  per  million  gallons 
of  water  is  obtained?  How  are  the  screenings  finally 
disposed  of? 

Obtain  and  record  any  data  regarding  the  operation  of 
the  screens  and  the  analysis  of  the  screenings. 

Fine  Screens.  —  What  type  of  fine  screen  is  employed  ? 


88 


DRAINAGE,  SEWERAGE,  SEWAGE-DISPOSAL 


When  was  it  built?  What  are  the  dimensions  of  the 
screen  ?  If  it  is  at  an  angle  to  the  sewage-flow,  what  is  the 
inclination?  How  much  sewage  is  the  screen  designed  to 
handle  efficiently?  How  is  the  screen  operated?  How 
much  screenings  is  obtained  per  million  gallons  of  sewage  ? 
What  is  the  aperture  of  the  screen?  Of  what  material  is 
it  made? 

Is  the  screen  cleaned  mechanically?  If  so,  describe  the 
method  employed.  Is  any  other  method  of  cleaning  em- 
ployed at  any  time  ?     If  so,  describe  this  also. 


Fig.  20.  A  storm-sewer  which  finally  empties  into  a  creek  1^  miles 
away.  Note  the  open  privy  on  the  left  bank.  The  photograph  was 
taken  during  dry  weather  and  shows  the  water  that  remains  in  the 
sewer.  This  is  an  excellent  breeding-place  for  mosquitoes  and  may 
have  some  relationship  to  the  malaria  which  was  prevalent  in  this 
section. 

How  are  the  screenings  finally  disposed  of?  Is  the 
operation  of  the  screen  controlled  by  laboratory  tests? 
If  so,  how  often  are  these  tests  made,  and  by  whom?  Is 
the  screen  efficient  and  economical  ? 


PLAIN  SEDIMENTATION  89 

Obtain  and  record  any  data  regarding  the  operation  of 
the  screens  or  the  analysis  of  the  screenings. 

Detritus  Tanks.  —  What  are  tlie  dimensions  of  the  tank? 
When  was  it  built?  Of  what  material  is  it  constructed? 
What  is  its  capacity?  How  long  does  the  sewage  remain 
in  this  tank?  Is  the  sewage  pumped  to  this  tank,  or  does 
it  reach  it  by  gravity  ?  If  the  tank  is  elevated,  what  is  the 
elevation  ? 

Has  the  tank  baffles,  or  other  devices  for  increasing  its 
efficiency?  Where  are  the  inlet  and  outlet  located?  Are 
they  satisfactorily  arranged? 

How  often  is  the  tank  cleaned?  What  method  of  clean- 
ing is  employed?  How  is  the  sludge  finally  disposed  of? 
How  much  sludge  is  obtained  per  million  gallons  of  sew- 
age? Is  the  operation  of  the  tank  controlled  by  labora- 
tory tests?  If  so,  how  often  are  these  tests  made,  and  by 
whom?  Obtain  and  record  any  data  regarding  the  opera- 
tion of  the  tank  and  the  analysis  of  the  sludge. 

Plain  Sedimentation.  —  What  are  the  dimensions  of  the 
tank?  What  is  its  capacity?  How  many  hours'  flow  can 
it  hold?  When  was  it  built?  Of  what  material  is  it  con- 
structed? How  many  units  are  available?  Are  they 
operated  in  series  or  in  parallel?  Is  the  direction  of  flow 
through  the  tank  horizontal  or  vertical?  Are  the  tanks 
open  or  covered? 

What  is  the  period  of  retention  in  each  tank?  How 
much  sewage  flows  through  per  day  ?  What  is  the  average 
velocity  of  flow  through  the  tank?  Does  the  tank  have 
baffles  or  other  facihties  which  presumably  increase  its 
efficiency  of  operation?  If  so,  where  are  these  located  in 
the  tank,  and  what  is  the  depth  of  each?  Where  are  the 
inlet  and  outlet  located?  Are  these  arranged  in  such  a 
manner  as  to  theoretically  yield  the  most  satisfactory 
results?  How  is  the  amount  of  flow  passing  through  the 
tank  regulated? 


90 


DRAINAGE,   SEWERAGE,  SEWAGE-DISPOSAL 


How  often  is  the  tank  cleaned  ?  What  method  of  clean- 
ing is  employed  ?  How  much  sludge  is  obtained  per  million 
gallons  of  sewage  ?     How  is  the  sludge  finally  disposed  of  ? 


Fig.  21.  An  open  privy  showing  much  filth  and  refuse  on  the 
ground  and  a  large  pool  of  water  which  serves  as  a  splendid  breeding- 
place  for  mosquitoes. 

Is  the  operation  of  the  tank  controlled  by  laboratory 
tests  ?     If  so,  how  often  are  these  tests  made,  and  by  whom  ? 


IMHOFF  TANK  TREATMENT  91 

Obtain  and  record  any  data  regarding  the  operation  of  the 
tank  and  the  analysis  of  the  sludge. 

Septic  Tank  Treatment.  —  What  are  the  dimensions  of 
the  tank?  What  is  its  capacity?  How  many  hom's'  flow 
can  it  hold?  How  much  sewage  flows  through  the  tank 
per  day  ?  When  was  it  built  ?  Of  what  material  is  it  con- 
structed ?  How  many  units  are  available  ?  Are  the  tanks 
operated  in  series  or  in  parallel?  Is  the  direction  of  flow 
through  each  tank  horizontal,  radial  or  vertical?  Are 
the  tanks  open  or  covered? 

What  is  the  period  of  retention  in  each  tank?  What  is 
the  average  velocity  of  flow  through  the  tank?  How  is  the 
amount  of  flow  passing  through  the  tank  regulated?  Does 
the  tank  have  baffles  or  other  devices  which  presumably 
increase  its  efficiency  of  operation?  If  so,  where  are  these 
located  in  the  tank  and  what  is  the  depth  of  each  ?  Where 
are  the  inlet  and  outlet  located?  Are  these  arranged  in 
such  a  manner  as  to  theoretically  yield  the  most  satis- 
factory results?  Does  the  sewage  reach  the  tank  by  grav- 
ity or  is  it  pumped?     If  so,  to  what  elevation  is  it  raised? 

How  often  is  the  tank  cleaned  ?  What  method  of  clean- 
ing is  employed  ?  How  much  sludge  is  obtained  per  million 
gallons  of  sewage?  How  is  the  sludge  finally  disposed  of? 
How  is  the  scum  treated  when  it  forms? 

Is  the  operation  of  the  tank  supervised  and  controlled 
by  laboratory  tests  ?  If  so,  how  often  are  these  tests  made, 
and  by  whom  ?  Obtain  and  record  any  data  regarding  the 
operation  of  the  tank  and  the  analysis  of  the  sludge. 

Imhoff  Tank  Treatment.  —  What  are  the  dimensions  of 
the  tank?  How  deep  is  the  sedimentation  chamber?  At 
what  depth  do  the  sides  of  the  sedimentation  chamber 
begin  to  slope,  and  what  is  the  angle  of  inclination  to  the 
vertical  ?  What  is  the  capacity  of  the  sedimentation 
chamber?  What  is  the  capacity  of  the  sludge-chamber? 
How  large  is  the  slot?     How  is  it   made?     What  means 


92  DRAINAGE,  SEWERAGE,  SEWAGE-DISPOSAL 

are  employed  to  prevent  the  gas  from  the  sludge  chamber 
entering  the  sedimentation  chamber  ?  Of  what  material  is 
each  tank  built?     How  many  tanks  are  in  use? 

How  much  sewage  flows  through  the  tank  per  day? 
What  is  the  period  of  retention?  What  is  the  velocity  of 
flow  through  the  tank?  How  is  the  amount  of  flow  pass- 
ing through  the  tank  regulated?  Are  the  tanks  in  series 
or  in  parallel  ?  Is  the  direction  of  flow  through  each  tank 
horizontal  or  vertical?  Are  the  tanks  open  or  covered? 
Is  the  tank  provided  with  baffles  or  other  devices  which 
presumably  increase  its  efficiency  of  operation?  If  so, 
where  are  these  located  in  the  tank,  and  what  is  the  depth 
of  each  ? 

Where  are  the  inlet  and  outlet?  Are  these  arranged  in 
such  a  manner  as  to  theoretically  yield  the  most  satisfac- 
tory results?  Is  the  sewage,  on  entering  the  tank,  distri- 
])uted  in  any  definite  or  special  way  in  order  to  equalize 
the  distribution  of  suspended  matter  in  the  sewage?  Does 
the  sewage-flow  reach  the  tank  by  gravity  or  is  it  pumped  ? 
If  so,  to  what  elevation  is  it  raised  ? 

During  what  months  of  the  year  is  sludge  drawn  from 
the  tank?  At  what  intervals  is  sludge  removed  from  the 
tank  during  this  period?  Is  the  sludge  treated  on  drying- 
beds,  after  withdrawal  ?  How  many  dr^dng-beds  are  avail- 
able? What  is  the  area  of  each?  Of  what  materials  is 
each  bed  constructed?  To  what  depth  is  the  sludge 
allowed  to  flow  onto  the  drying-bed?  How  much  sludge 
is  withdrawn  at  any  given  time?  What  is  the  water- 
content  of  the  sludge?  How  long  is  the  sludge  allowed  to 
dry  before  it  is  removed?  What  is  the  water-content  of 
the  dried  sludge?  How  is  the  dried  sludge  finality  dis- 
posed of?  Is  any  other  method  than  drying  employed  in 
the  treatment  of  the  wet  sludge?  If  so,  describe  in  detail. 
If  possible,  obtain  information  regarding  the  amount  of 
sludge  obtained  per  million  gallons  of  sewage  treated. 


COAGULATION   BY   CHEMICAL   TREATMENT  93 

Does  any  scum  form  in  the  sedimentation  chamber? 
Does  any  scum  form  in  the  gas- vents  ?  If  so,  what  method 
is  employed  to  overcome  this  undesirable  feature  of  the 
operation  of  the  tank? 

Is  the  operation  of  the  tank  supervised  and  controlled 
by  laboratory  tests  ?  If  so,  how  often  are  these  tests  made, 
and  by  whom?  Obtain  and  record  any  data  regarding 
the  operation  of  the  tank  and  the  analysis  of  the  sludge. 

Coagulation  by  Chemical  Treatment.  —  What  are  the 
dimensions  of  the  tank?  What  is  its  capacity?  How 
much  sewage  flows  through  per  day?  When  was  it  built? 
Of  what  material  is  it  constructed?  How  many  units  are 
available?  Is  the  direction  of  flow  thr«ough  each  tank 
horizontal  or  vertical?  Are  the  tanks  operated  in  series 
or  in  parallel?     Are  the  tanks  open  or  covered? 

What  is  the  period  of  retention  in  each  tank?  What  is 
the  average  velocity  of  flow  through  the  tank  ?  How  is  the 
amount  of  flow  passing  through  the  tank  regulated?  Is 
the  tank  provided  with  baffles  or  other  devices  which  pre- 
sumably increase  its  efficiency  of  operation?  If  so,  where 
are  these  located  in  the  tank,  and  what  is  the  depth  of 
each? 

Where  are  the  inlet  and  outlet  located?  Are  they  ar- 
ranged in  such  a  manner  as  to  theoretically  yield  the  most 
satisfactory  results?  Does  the  sewage  reach  the  tank  by 
gravity,  or  is  it  pumped?  If  pumped,  to  what  elevation 
is  it  raised? 

What  chemicals  are  used  as  coagulants?  How  are  the 
chemicals  applied?  What  precautions  are  taken  to  mix 
the  chemicals  thoroughly  with  the  sewage?  How  much 
of  each  chemical  is  used  per  million  gallons  of  sewage? 

How  often  is  each  tank  cleaned  ?  What  method  of  clean- 
ing is  employed?  How  much  sludge  is  obtained  per 
million  gallons  of  sewage?  What  is  the  water-content  of 
the  sludge?     How  is  the  sludge  treated?     If  the  sludge  is 


94 


DRAINAGE,  SEWERAGE,  SEWAGE-DISPOSAL 


pressed,  what  is  the  water-content  of  tne  pressed  sludge? 
Is  the  pressed  sludge  utilized  in  any  way?  If  so,  describe 
how  it  is  utilized,  and,  if  possible,  ascertain  the  revenue 
derived  from  this  source,  in  order  to  determine  to 
what  extent  the  treatment  of  the  sewage  is  paying  for 
itself. 

Is  the  operation  of  the  tank  supervised  and  controlled 
by  laboratory  tests  ?  If  so,  how  often  are  these  tests  made, 
and  by  whom?  Obtain  and  record  any  data  regarding 
the  operation  of  the  tank  and  the  analysis  of  the  sludsje. 


Fig.  22.  An  open  drain  showing  .some  water  during  a  long  dry 
period.  Mosquitoes  were  found  actively  breeding  in  some  water  under 
the  bridge. 

Broad  Irrigation  or  Sewage-Farming.  —  When  was  broad 
irrigation  introduced  to  treat  the  sewage?  How  much 
land  is  available  for  this  purpose?  How  often  is  the 
sewage  applied?  How  many  gallons  are  applied  at  each 
dose?  What  is  the  dosage  per  acre  per  day?  How  is 
the  sewage  applied?  Are  any  precautions  taken  to  apply 
the  sewage  uniformly?      Does  the  sewage   flow  onto  the 


INTERMITTENT  SAND  FILTRATION  95 

land  by  gravity  or  is  it  pumped?     If  the  latter,  to  what 
elevation  is  it  pumped? 

What  crops  are  grown  on  the  sewage-farm?  What  is 
the  normal  yield  of  each  crop?  What  is  the  total  annual 
income  derived  from  the  crops?  What  precautions  are 
taken  to  prevent  or  overcome  clogging?  Is  the  operation 
of  the  sewage-farm  supervised  and  controlled  by  labora- 
tory tests?  If  so,  how  often  are  these  tests  made,  and  by 
whom?  Obtain  and  record  any  data  regarding  the  opera- 
tion of  the  sewage-farm  and  the  results  obtained. 

Intermittent  Sand  Filtration.  —  When  were  the  sand 
filters  first  built  ?  How  many  filters  are  in  use  ?  What  is 
the  area  of  each?  Is  each  filter  underdrained?  If  so, 
what  method  of  underdraining  is  employed?  How  deep 
are  the  underdrains  laid?  Where  do  the  underdrains 
finally  discharge  ?     Are  the  underdrains  ventilated  ? 

Does  the  sewage  reach  the  filter-beds  by  gravity,  or  is 
it  pumped?  If  pumped,  to  what  elevation  is  it  raised? 
How  is  the  sewage  applied  on  the  beds  ?  What  precautions 
are  taken  to  distribute  the  sewage  uniformly  on  the  bed? 
Is  the  bed  open  or  covered?  What  is  the  effective  size  of 
the  sand  ?     What  is  the  uniformity  coefficient  of  the  sand  ? 

How  much  sewage  is  applied  at  each  dose?  How  many 
doses  are  applied  during  twenty-four  hours?  What  is  the 
period  during  which  the  sewage  is  applied?  How  long  is 
the  rest  period?  How  much  sewage  is  treated  per  acre 
per  day?  What  precautions  are  taken  to  prevent  clog- 
ging? How  often  is  the  bed  cleaned?  Describe  the 
method  used  in  cleaning  the  bed.  What  precautions  are 
taken  to  prevent  freezing? 

Is  the  operation  of  the  bed  supervised  and  controlled  by 
laboratory  tests?  If  so,  how  often  are  these  tests  made, 
and  by  whom?  Obtain  and  record  any  data  regarding 
the  operation  of  the  filter-bed  and  the  quality  of  the 
effluent. 


96  DRAINAGE,  SEWERAGE,  SEWAGE-DISPOSAL 

Contact  Filtration.  —  When  was  the  first  contact  filter 
put  into  operation?  Of  what  material  is  it  made?  How 
many  filters  are  in  use?  What  is  the  area  of  each?  What 
is  the  depth  of  each  filter?  Are  the  filters  operated  in 
series  or  in  parallel?  What  is  the  filtering  medium? 
What  are  the  minimum  and  maximum  sizes  of  the  filtering 
medium?     Where  is  the  final  effluent  discharged? 

How  much  sewage  is  applied  at  each  dose?  How  long 
is  the  period  of  fiUing?  How  often  during  twenty-four 
hours  is  the  bed  filled?  How  long  is  the  rest  period? 
How  much  sewage  is  treated  per  acre  per  day?  Does  the 
sewage  reach  the  bed  by  gravity  or  is  it  pumped?  If 
pumped,  how  high  is  it  elevated? 

What  precautions  are  taken  to  prevent  clogging?  How 
often  is  each  bed  cleaned?  Describe  the  method  employed 
in  cleaning  the  bed.  Is  the  bed  open  or  covered?  What 
precautions  are  taken  to  prevent  freezing? 

Is  the  operation  of  the  bed  supervised  and  controlled 
by  laboratory  tests?  If  so,  how  often  are  these  tests 
made,  and  by  whom?  Obtain  and  record  any  data  regard- 
ing the  operation  of  the  filter-bed,  and  the  quality  of  the 
effluent. 

Trickling  Filtration.  —  When  was  the  first  trickling  filter 
put  into  operation?  Of  what  material  is  it  made?  How 
many  filters  are  in  use?  What  is  the  area  of  each? 
What  is  the  depth  of  each  filter?  What  is  the  filtering 
medium?  What  are  the  minimum  and  maximum  sizes 
of  the  filtering  medium?  Where  is  the  final  effluent 
discharged  ? 

How  is  the  sewage  applied  to  the  filter?  How  much 
sewage  is  applied  at  each  dose?  What  method  is  employed 
to  cUstributc  the  sewage  uniformly  over  the  bed?  If  a 
nozzle  is  in  use,  what  is  the  type  employed?  What  is  the 
maxinuim  head  maintained  on  each  nozzle?  Is  the  equal 
distribution  on  the  filter  produced  by  a  faUing  head? 


ACTIVATED  SLUDGE  97 

What  are  the  dimensions  of  each  dosing  tank?  How  is 
the  dosing  chamber  filled?  What  is  the  period  required 
for  a  dose  to  be  completely  discharged  ?  What  is  the  rest 
period  between  doses?  What  is  the  rate  of  treatment  per 
acre  per  day?  Does  the  sewage  reach  the  dosing  chamber 
by  gravity,  or  is  it  pumped  ?  If  the  latter,  how  high  is  it 
elevated  ?  Has  the  filter  shown  any  signs  of  clogging  ?  If 
so,  what  measures  are  taken  to  overcome  it?  Is  the  bed 
open  or  covered?  What  precautions  are  taken  to  prevent 
freezing?  Is  the  normal  ventilation  which  takes  place 
during  filtration  supplemented  in  any  way  ?  If  the  effluent 
is  treated  by  secondary  sedimentation,  ascertain  the 
method  employed,  and  answer  the  questions  recorded  for 
that  process. 

Is  the  operation  of  the  bed  supervised  and  controlled 
by  laboratory  tests?  If  so,  how  often  are  these  tests 
made,  and  by  whom?  Obtain  and  record  any  data  regard- 
ing the  operation  of  the  filter-bed  and  the  quaUty  of  the 
effluent. 

Activated  Sludge.  —  When  was  the  activated  sludge  plant 
put  into  operation?  How  many  units  are  employed  in 
treating  the  sewage  by  this  method?  Of  what  material  is 
each  unit  made?  Are  the  tanks  operated  on  the  con- 
tinuous plan  or  on  the  fiU-and-draw  basis? 

What  are  the  dimensions  of  each  tank?  What  is  the 
capacity  of  each  tank?  If  tanks  are  operated  on  the 
continuous  plan,  describe  their  construction  in  detail.  In 
this  case,  the  tank  will  resemble  the  ordinary  Imhoff  tank 
in  construction,  and  many  of  the  questions  suggested  under 
that  head  are  applicable  here.  It  is  assumed  that  the 
surveyor  will  have  enough  engineering  knowledge  and 
sufficient  grasp  of  the  subject  of  sewage-disposal  to  be  able 
to  select  those  questions  which  apply.  If  operated  on  the 
fill-and-draw  plan,  the  surveyor  should  determine  the  time 
required   for   filling,   the   time   required   for   aerating,    the 


98  DRAINAGE,  SEWERAGE,  SEWAGE-DISPOSAL 

time  during  which  the  activated  sludge  is  settHng  out, 
and  the  time  required  for  withdrawing  the  supernatant 
hquid. 

In  either  case,  what  is  the  proportion  of  the  activated 
sludge  to  sewage  treated?  How  much  air  is  applied  per 
minute?  Under  the  existing  conditions  of  operation,  how 
much  air  is  being  applied  per  gallon  of  sewage  per 
minute? 

Where  is  the  inlet  for  the  sewage  located?  Does  the 
sewage  enter  the  tank  by  gravity,  or  is  it  pumped  into 


^^ 


T^fW!?? 


it 


Fig.  23.     Another  open  drain  which  contained  much  toul  sewage. 
The  vegetation  aided  in  keeping  water  in  the  drain  constantly. 

the  tank?     If  pumped,   to   what   elevation  is  it  raised? 
How  is  the  volume  of  sewage  treated  determined? 

From  what  source  is  the  air  derived  ?  Is  the  air  applied 
through  porous  plates  or  perforated  pipes?  If  neither  of 
these  methods  is  used,  describe  the  method  employed. 
Where  is  the  air-inlet  located  in  the  tank?  How  many  in- 
lets are  available?  If  perforated  pipe  is  used,  what  is  the 
size  of  the  perforations? 


DISINFECTION  99 

On  the  basis  of  an  acre  per  day,  how  many  gallons  of 
sewage  are  treated  ?  How  often  must  the  activated  sludge, 
which  has  become  inactivated,  be  replaced  by  activated 
sludge?  How  much  reactivated  sludge  is  usually  added? 
What  method  is  employed  to  reactivate  the  inactivated 
sludge?  What  becomes  of  the  excess  amount  of  activated 
sludge?  Is  it  treated  in  any  way?  If  so,  describe  the 
method.  What  financial  return,  if  any,  is  obtained  from 
the  activated  sludge? 

Is  the  operation  of  the  activated  sludge  plant  supervised 
and  controlled  by  laboratory  tests?  If  so,  how  often  are 
these  tests  made,  and  by  whom?  Obtain  and  record  any 
data  regarding  the  operation  of  the  activated  sludge 
process,  and  the  quality  of  the  effluent. 

Disinfection.  —  What  method  of  disinfection  is  em- 
ployed? When  was  disinfection  first  introduced?  If 
chlorine  gas  is  used,  how  is  it  applied?  If  hypochlorite  is 
used,  how  is  that  applied?  Where  is  the  disinfectant 
added  ?  Is  it  added  at  the  point  where  it  is  most  effective  ? 
How  long  is  the  disinfectant  allowed  to  act  on  the  sewage 
or  sewage-effluent? 

What  amount  of  chlorine,  in  parts  per  milhon,  is  used 
for  disinfection?  How  is  the  efficiency  of  disinfection 
determined?  Are  regular  bacteriological  tests  made  to 
determine  the  efficiency  of  disinfection?  Is  the  sewage 
or  sewage-effluent  disinfected  throughout  the  entire  year? 
If  not,  during  what  months  of  the  year  is  disinfection  prac- 
tised?    For    what    ultimate    purpose    is    the    disinfectant 

added  ? 

There  are  otner  methods  of  treating  sewage,  such  as  the 
electrolytic  method,  the  Miles  acid  process,  the  ozone 
method  of  disinfection,  and  many  others  which  are  not 
patented.  These  methods  are  not  discussed  here,  because 
they  are  not  widely  used.  The  Miles  acid  process  has 
been   the  subject  of   much   discussion  recently,  and  such 


100        DRAINAGE,   SEWERAGE,  SEWAGE-DLSPOiSAL 

experts  as  Professor  Robert  Spurr  Weston,  and  Professor 
C.-E.  A.  Winslow,  have  spoken  favorably  of  it.^ 

In  writing  the  report  on  the  chapter  on  sewerage  and 
sewage-disposal,  the  surveyor  may  find  the  following  table 
of  some  aid.  No  tables  are  recorded  here  in  which  to  in- 
sert the  results  of  bacteriological  and  chemical  analyses. 
The  number  and  the  nature  of  the  tests  not  only  vary 
with  the  process  employed,  but  also  depend  upon  the 
methods  followed  by  the  superintendent  of  the  sewage- 
treatment  plant.  In  general,  however,  the  tables  will  be 
similar  to  those  inserted  for  the  results  of  the  water  ex- 
aminations, except  that  such  tests  as  relative  stability, 
dissolved  oxygen,  dissolved  oxygen  demand,  suspended 
solids  and  other  similar  tests,  which  are  more  applicable  to 
sewage  and  sewage-sludge,  should  be  included. 


TABLE  4 

SHOWING   THE   NAME,   LOCATION,   LENGTH,   AND    SIZE   OF 

THE   SEWERS 


Name  of  sewer. 

Location  of  sewer. 

Length  of  sewer. 

Size. 

1 

^  Miles  Acid  Treatment  of  Sewage  at  New  Haven,  Conn.,  Municipal 
Journal,  Vol.  XLV,  Oct.  12,  19,  26,  1918.  By  C.-E.  A.  Winslow  and 
F.  W.  Mohlman. 

Tests  of  a  Process  of  Sewage  Purification  with  Grease  Recovery  and 
Apparent  Profit,  American  Journal  of  Public  Health,  Vol.  VI,  1916, 
pages  334-343.     By  Robert  Spurr  Weston. 


OUTLINE  0£  »I^HAFTER. 


101 


>     ■>  1  > )  > 


TABLE  4:  — Continued 


Name  of  storm-sewer. 


Location  ol  sew  er. 


Length  of  sewer. 


Size. 


OUTLINE    OF    CHAPTER    ON    DRAINAGE,    SEWERAGE   AND 

SEWAGE-DISPOSAL 

1.  Importance  of  adequate  sewerage  and  sewage-disposal  to  the 
health  of  a  community;  methods  of  treating  sewage  and  their  applica- 
bihty  to  different  conditions;  a  sewerage  system  as  a  necessary  means 
for  facilitating  the  practice  of  good  personal  hygiene;  effect  of  the  in- 
troduction of  a  sewerage  system  on  prevalence  of  intestinal  diseases 
and  death  rate  resulting  from  them. 

2.  Extent  to  which  city  is  sewered. 

Area,  population  included,  houses  not  connected  to  sewers  although 
the  latter  are  available. 

3.  Separate  or  combined  plan;   provision  for  removing  storm-water. 

4.  liocation  and  size  of  sewer-outfalls. 

6.  Specific  nuisances  or  problems  due  to  inadequate  or  improper 
sewage-disposal;  operation  of  sewage-disposal  plant;  results;  person- 
nel. 

6.  The  privy  problem. 

a.  Number  of  privies  in  use. 
h.  Protected  or  unprotected. 

c.  Distribution  of  privies  in  city,  shown  by  spot-map. 

d.  Photographs. 

7.  Previous  studies  on  drainage,  sewerage  and  sewage-disposal  in- 
cluding description  of  present  projects. 

8.  Summary. 

9.  Recommendations. 


CHAPTER   VII 
COLLECTION   AND   DISPOSAL   OF  REFUSE 

Collection  and  Disposal  of  Refuse  a  Serious  Municipal 
Problem.  —  As  stated  in  the  previous  chapter  the  wastes 
of  the  human  body,  and  of  human  activities,  may  be 
divided  into  two  classes,  the  liquid  and  the  soUd  wastes. 
It  has  already  been  pointed  out,  that  the  rapid  and  satis- 
factory removal  of  liquid  wastes  is  exceedingly  important 
from  the  pubHc  health  standpoint.  The  collection  and 
disposal  of  solid  wastes  present  a  vexing  municipal  problem, 
and  one  that  is  totally  different  from  the  problems  involved 
in  the  disposal  of  liquid  wastes. 

Definition  of  Terms.  —  The  solid  wastes  of  a  city  con- 
sist of  a  varied  mass  of  things,  some  organic  and  others 
inorganic  in  composition,  some  offensive  and  others  in- 
offensive. The  solid  wastes  are  usually  classified  under 
various  heads,  garbage  being  the  term  applied  to  the  solid 
wastes  obtained  from  the  dining-room  and  the  kitchen, 
while  the  term  rubbish  is  applied  to  paper,  tin  cans,  rags, 
junk,  old  leather,  old  furniture  and  similar  objects.  Much 
of  what  is  considered  rubbish  is  usually  combustible. 
Ashes  is  the  term  applied  to  the  solid  wastes  from  burnt 
coal  or  wood.  These  three  terms  —  garbage,  rubbish  and 
ashes  —  are  referred  to  collectively  as  refuse. 

Other  terms  are  also  employed  to  designate  other  solid 
waste  materials.  The  term  "street  sweepings"  is  self 
explanatory.  It  represents  the  solid  wastes  obtained  by 
sweeping  the  streets.  The  character  of  these  wastes  will 
vary  considerably  with  the  location  of  the  source,  the 
nature  of  the  district  and  its  use,  the  character  of  the 

102 


DISPOSAL  OF  DEAD  ANIMALS 


103 


paving,  the  amount  oi  traffic,  the  number  of  horses,  and 
other  similar  factors.  These  wastes  will  be  partly  organic 
and  partly  inorganic  in  composition.  The  inorganic 
matter  will  be  gritty  in  character,  and  may  consist  of 
small  particles  of  sand,  or  of  the  pulverized  paving.  Street 
sweepings,  however,  sometimes  contain  a  considerable 
amount  of  organic  matter,  which  may  become  quite 
offensive. 


tiG.  24.  An  open  stable  in  the  heart  of  a  city  showing  a  large  heap 
of  manure  in  which  flies  were  actively  breeding. 

Disposal  of  Dead  Animals  also  a  Vexing  Municipal 
Problem.  —  Another  form  of  solid  waste  which  presents  a 
serious  problem  for  every  community  is  the  disposal  of 
dead  animals.  In  every  community  a  considerable  num- 
ber of  horses,  cows,  dogs,  cats  and  chickens  die  every  year; 
and  sometimes  there  are  other  animals  to  be  considered. 
All  these  must  be  collected  and  disposed  of,  in  some  satis- 
factory way,  usually  either  by  burial  or  by  incineration,, 
Some  dead  animals  can  be  treated  in  rendering  or  reduc- 
tion plants  and  in  that  way  serve  as  a  source  of  income. 


104  COLLECTION  AND  DISPOSAL  OF  REFUSE 

Disposal  of  Slaughter-House  Wastes.  —  Other  wastes 
which  are  frequently  encountered  are  those  of  slaughter- 
houses. These  wastes  are  very  offensive  and  must  be 
treated  rapidly  in  order  to  avoid  a  nuisance.  They  are 
probably  best  disposed  of  by  reduction,  as  serious  nuisances 
are  likely  to  arise  from  their  incineration  or  burial. 

Disposal  of  Snow.  —  The  removal  of  snow  is  a  problem 
which  is  pecuhar  to  northern  cities,  and  which  is  sometimes 
both  difficult  and  expensive.  In  most  cases,  the  snow  has 
to  be  shovelled  into  wagons,  and  the  contents  removed 
either  to  the  nearest  stream  or  the  neare3t  dumping-lot. 
In  other  cases,  where  the  sewers  are  large,  and  the  sewage- 
flow  is  great,  the  snow  is  shovelled  into  the  sewers  through 
open  manholes,  and  disposed  of  in  that  way. 

Disposal  of  Manure.  —  The  collection  and  disposal  of 
animal  wastes,  such  as  manure,  is  another  very  serious 
problem.  In  most  communities  no  provision  is  made  for 
collection  and  disposal  of  manure,  and  it  is  customary  to 
find  large  piles  of  manure  wherever  horses  or  cows  are 
stabled.  The  manure-piles  are  excellent  breeding-places 
for  flies,  and  doubtless  are  responsible  for  the  breeding  of 
millions  and  millions  of  flies  during  the  warmer  months 
of  the  year.  The  flies  may  be  indirectly  responsible  for 
the  transmission  of  disease,  since  they  can  carry  germs  of 
all  kinds  on  their  legs.  Thus  the  presence  of  fly-breeding 
manure-piles  may  become  a  public  health  problem,  and 
one  which  is  usually  very  difficult  to  solve.  Manure  serves 
as  an  excellent  fertilizer  and  therefore  has  a  definite  eco- 
nomic value;  as  a  result  the  scavenger  is  not  allowed  to 
remove  it.  In  some  cases,  stable  owners  and  others  have 
been  lequired  to  treat  their  manure  by  using  borax  or 
hellebore  or  some  other  chemical  substance.  Good  results 
have  been  claimed  for  these  methods;  but  in  actual  prac- 
tice the  treatment  is  apt  to  be  careless  or  insufficient,  and 
fly-breeding  usually  takes  place  in  spite  of  it. 


DISPOSAL  OF  MANURE  105 

One  requirement  that  will  assist  in  diminishing  the  fly 
nuisance,  however,  is  that  the  manure  should  be  collected 
as  soon  as  possible  after  it  is  excreted,  so  that  it  will  not 
become  infected  with  the  eggs  of  flies.  The  manure  should 
be  placed  in  a  covered  wooden  box  which  has  a  concrete 
bottom  to  prevent  the  larv2e  from  penetrating  the  ground. 
If  the  cover  can  be  arranged  so  that  part  of  it  opens  into 
a  fly  trap,  most  of  the  flies  that  develop  will  be  caught  in 
this  way  and  destroyed. 


-«r" 


Fig.  25.  A  pile  of  manure  covering  an  area  of  three  to  four  acres 
and  over  nine  feet  in  height,  not  far  from  a  thickly  inhabited  section  of  a 
large  city.  The  man  in  the  picture  is  6  feet  3  inches  tall.  The  manure- 
pile  is  constantly  burning.  It  is  doubtful  whether  the  fly  nuisance  is 
entirely  overcome  by  this  method  of  treatment.  The  ashes  are  placed 
in  bags  and  sold  as  fertilizer. 

Another  means  of  diminishing  the  number  of  flies  is  to 
cover  all  fresh  manure  with  earth.  The  eggs  that  have 
already  been  deposited  in  the  manure  will  develop  into 
flies,  but  the  covered  manure  will  not  serve  as  a  breeding- 
place  for  other  flies. 

Municipal  Collection  and  Disposal  of  Refuse  the  Most 
Satisfactory.  —  The  problem  of  refuse  collection  and  dis- 


106  COLLECTION  AND  DISPOSAL  OF  REFUSE 

posal  usually  causes  great  annoyance  in  a  community. 
This  is  due  primarily  to  the  variation  in  methods  which 
exists  in  different  communities.  A  municipal  system  of 
collection  and  disposal  is  the  most  satisfactory  of  all,  and, 
under  such  a  system,  the  nuisances  and  annoyances  are 
usually  reduced  to  a  minimum.  In  some  communities, 
however,  private  scavengers  at  least  remove  the  refuse 
and  sometimes  also  dispose  of  it.  In  some  cities  the 
scavenger  is  employed  by  the  city  to  perform  the  work; 
in  others,  he  is  simply  Ucensed,  and  performs  the  work 
without  remuneration  from  the  city  or  the  residents. 
Sometimes  he  agrees  to  pay  the  city  a  definite  annual  fee 
for  permission  to  collect  the  refuse.  In  still  other  cases, 
the  scavenger  is  not  remunerated  by  the  city,  and  pays  no 
fee  for  the  privilege  of  collecting  the  refuse,  but  charges 
each  family  whom  he  serves,  a  definite  monthly  fee.  In 
such  cases,  large  sections  of  the  population  do  not  employ 
the  scavenger,  but  attempt  to  dispose  of  their  refuse 
privately.     This  leads  to  many  serious  nuisances. 

The  people  have  apparently  come  to  regard  the  collec- 
tion of  refuse  as  a  municipal  function  like  the  building  of 
sewerage  and  water-supply  systems.  They  are  wilUng  to 
pay  for  this  service  out  of  the  general  tax  fund,  but  they 
are  unwilling  to  pay  a  separate  tax  to  a  private  scavenger 
in  order  to  have  their  refuse  removed.  Thus,  where  a  free 
municipal  system  of  refuse  collection  is  in  use,  almost 
every  resident  is  served,  and  is  satisfied  in  spite  of  the 
fact  that  the  people  are  paying  indirectly  for  this  service 
through  the  general  tax.  Every  resident  is  also  willing  to 
be  served  by  the  scavenger  who  collects  the  refuse  without 
charge. 

It  is  obvious,  therefore,  that  the  two  systems  which  will 
give  the  best  service  are  free  collection  and  disposal  of 
refuse  by  the  community,  and  free  collection  and  disposal 
of  refuse  by  a  private  scavenger  who  does  not  charge  the 


COLLECTION  AND   DISPOSAL  OF  REFUSE 


107 


people  a  direct  tax  or  fee  for  the  service.  Either  system 
will  be  successful,  since,  in  either  case,  the  number  of 
people  who  will  dispose  of  their  refuse  privately  will  be 
small,  and  the  number  of  local  nuisances  will  be  greatly 
diminished.  Either  one  of  these  two  systems  should  be 
employed  in  every  community.  The  author  believes,  how- 
ever, that  a  free  municipal  system  of  collection  and  dis- 
posal of  refuse  is  the  most  desirable. 


Fig.  26.     An  open  wagon  used  for  collecting  garbage.     This  wagon 
is  neither  water-tight  nor  is  it  protected  against  flies. 


C( 


Collection  and  Disposal  of  Refuse  Primarily  an  Engineer- 
ing Problem.  —  There  has  been  considerable  discussion  as 
to  whether  the  collection  and  disposal  of  refuse  is  a  func- 
tion of  the  health  department,  or  of  some  other  local 
department.  It  is  doubtless  true  that  the  danger  to  the 
public  health  from  improperly  disposed  garbage  is  small. 
The  objections  to  improperly  disposed  garbage  are  that  a 
fly  nuisance  may  result,  or  that  foul  odors  may  be  given  off. 
The  indirect  danger  due  to  flies  has  already  been  indicated. 
It  is  difficult  to  state  exactly  how  many  deaths  flies  may 


108  COLLECTION  AND  DLSPOSAL  OF  REFUSE 

indirectly  cause  per  annum.  Under  such  conditions  as 
existed  in  the  camps  during  the  Spanish-American  war, 
the  number  may  be  large;  but  in  most  communities  it  is 
exceedingly  doubtful  whether  the  toll  due  to  flies  is  at  all 
large.  Witness  the  exceedingly  low  typhoid  death-rates 
in  communities  where  the  water-supply  is  good,  the  milk- 
supply  is  satisfactory,  privies  are  practically  absent,  and 
food  handlers  are  thoroughly  examined. 

It  must  be  borne  in  mind  that  germs  transmitted  by 
flies  are  primarily  of  fecal  origin,  so  that  where  the  infant 
death-rate  from  diarrhea  is  low  and  the  typhoid  death- 
rate  is  also  low,  the  fly  is  probably  responsible  for  very 
few  deaths.  There  is  no  case  on  record,  as  far  as  the 
author  is  aware,  where  a  case  of  diphtheria,  scarlet  fever, 
tuberculosis  or  other  respiratory  disease  has  definitely 
been  traced  to  infection  obtained  from  or  carried  by  a  fly. 
That  such  a  thing  is  possible,  there  is  no  doubt;  but  its 
occurrence  is  very  unlikely.  The  danger  caused  by  the 
fly  is  therefore  probably  very  small,  under  the  conditions 
that  prevail  in  most  cities. 

The  only  reason  why  the  collection  and  disposal  of 
refuse  is  frequently  supervised  by  the  health  department  is 
that  the  people  have  become  accustomed  to  associating  the 
abatement  of  foul  odors  and  the  eradication  of  fly-breeding 
places,  with  the  functions  of  the  health  department.  The 
problem  of  collecting  and  disposing  of  refuse  is,  however, 
primarily  an  engineering  problem,  and  as  such  it  should 
be  under  the  direction  and  supervision  of  the  city  engineer, 
the  street  department,  or  the  department  of  street  cleaning. 
The  problem  can  doubtless  be  solved  much  more  satis- 
factorily and  economically  by  one  of  these  departments 
than  by  the  health  department.  Such  an  arrangement 
would  leave  the  health  officer  free  to  pursue  other  activities 
which  would  doubtless  aid  in  preventing  disease  and  pro- 
moting the  public  health. 


INFORMATION   DESIRED   CONCERNING  GARBAGE      109 

But  the  problem  cannot  and  should  not  oe  entirely  dis- 
sociated from  the  work  of  the  health  department.  Under 
any  circumstances  the  people  would  continue  to  report 
nuisances  due  to  improper  refuse  disposal  to  the  health 
department;  and,  as  the  term  health  must  not  only  be 
considered  to  mean  physical  or  bodily  health,  but  also 
comfort,  decency  and  welfare,  it  should  be  the  duty  of  the 
health  department  to  cooperate  with  the  responsible 
agency,  for  the  removal  of  objectionable  conditions.  The 
health  department  should  investigate  all  nuisances  due  to 
improper  refuse  disposal.  If  the  existence  of  a  nuisance 
is  confirmed,  the  responsible  agent  should  be  required  to 
remove  or  abate  it. 

Methods  for  Obtaining  Necessary  Data.  —  In  order  to 
get  the  information  regarding  the  methods  employed  for 
collecting  and  disposing  of  the  city's  refuse,  the  surveyor 
should  visit  and  interview  the  city  engineer,  the  health 
officer,  or  whoever  is  in  charge  of  this  service.  If  a  private 
scavenger  is  employed,  he  should  also  be  interviewed.  The 
information  suggested  by  the  questions  listed  below  should 
be  obtained.  In  addition  the  surveyor  should  arrange  to 
visit  the  dumps,  piggeries,  and  other  plants  employed  in 
treating  the  refuse. 

Information  Desired  Concerning  Garbage.  —  Who  is  re- 
sponsible for  the  collection  of  the  garbage?  If  a  private 
individual,  obtain  his  name  and  address.  If  the  munici- 
pality, obtain  the  name  and  title  of  the  person  directly 
responsible.  If  a  private  individual,  what  arrangement  has 
he  made  with  the  city  for  the  collection  of  the  garbage? 
Is  the  city  paid  an  annual  fee  for  permission  to  collect  the 
garbage?  If  so,  what  is  this  fee?  If  the  city  is  not  paid 
a  fee,  does  it  pay  one  to  the  scavenger?  If  so,  how  much 
is  this  fee? 

How  often  is  the  garbage  collected  in  winter?  How 
often  in  summer?     Is  the  garbage  separated  from  other 


no 


COLLECTION  AND  DISPOSAL  OF  REFUSE 


forms  of  refuse  before  it  is  collected?     Is  it  mixed  with 
other  forms  of  refuse  at  the  time  of  collection  ? 

Is  the  service  to  the  residents  performed  free  of  charge? 
If  not,  what  is  the  charge  for  residents  ?  What  is  the  charge 
for  restaurants  and  hotels?  How  often  is  garbage  col- 
lected from  restaurants  and  hotels?  What  is  the  approxi- 
mate total  cost  to  the  residents  for  having  the  garbage 
collected?  How  many  residents  and  business  places  em- 
ploy tb'^  FP'T''0'^c;«'^v? 


Wniffmi 


mmmmmmmm 


Fi(^  27.  An  uncovered,  water-tight  wiigon  loaded  with  garbage 
arriving  at  a  piggery.  The  garbage  was  swarming  with  flies.  Garbage 
wagons  should  always  be  covered  in  order  to  avoid  nuisances. 

Does  the  local  ordinance  require  the  use  of  covered  metal 
containers  for  the  garbage?     How  well  is  the  law  enforced? 

What  is  the  total  amount  of  garbage  collected  each 
month  during  the  year?  What  is  the  average  amount  of 
garbage  per  capita? 

How  many  wagons  are  employed  for  removing  the  gar- 
bage? What  is  the  ton-mileage  for  all  the  trucks  in  a 
definite  period  of  time?     Are  these  wagons  covered  and 


CONCERNING  RUBBISH  AND  ASHES 


111 


water-tight?  Are  they  opened  only  to  receive  garbage? 
What  sort  of  cover  is  employed?  What  are  the  dimen- 
sions of  each  wagon  ?  What  is  the  capacity  of  each  wagon  ? 
The  total  amount  of  garbage  collected  per  month  can  be 
determined  from  the  size  of  the  wagon-load  and  the  num- 
ber of  loads  per  month.  How  many  men  are  employed 
in  collecting  garbage  ? 

What  method  is  employed  for  disposing  of  the  garbage? 
Ascertain  the  location  of  the  place  of  disposal,  for  future 
inspection.  If  any  peculiar  method  of  collection  or  di^^- 
posal  is  encountered,  describe  it  in  detail. 


Fig.  28.  A  private  scavenger  arriving  at  a  dump  with  a  load  of 
rubbish.  The  residents  have  to  pay  a  special  fee  for  this  service, 
where  municipal  collections  are  not  made. 


Information  Desired  Concerning  Rubbish  and  Ashes. 
—  Who  is  responsible  for  the  collection  of  the  rubbish  and 
ashes?  If  a  private  individual,  obtain  his  name  and  ad- 
dress. If  the  municipality,  obtain  the  name  and  title  of 
the  person  directly  responsible.  If  a  private  individual, 
what  arrangement  has  he  made  with  the  city?     Is  the 


112  COLLECTION  AND  DISPOSAL  OF  REFUSE 

city  paid  an  annual  fee  for  permission  to  collect  the  rub- 
bish and  ashes  ?  If  so,  what  is  this  fee  ?  If  the  city  is  not 
paid  a  fee,  does  it  pay  one  to  the  scavenger?  If  so,  how 
much  is  this  fee? 

How  often  is  the  rubbish  collected  in  summer?  How 
often  in  winter?  How  often  are  the  ashes  collected  in 
summer?  How  often  in  winter?  What  sort  of  containers 
are  used  for  ashes?  How  is  the  rubbish  prepared  by  the 
resident  for  removal  ? 

Is  the  service  of  collecting  the  rubbish  and  ashes  per- 
formed free  of  charge  to  the  residents?  If  not,  what  is 
the  charge?  What  is  the  approximate  cost  to  the  resi- 
dents for  having  their  rubbish  and  ashes  removed?  This 
can  be  determined  by  obtaining  the  rates  that  prevail  and 
estimating  the  cost  from  the  frequency  and  amount  of 
service  rendered. 

How  much  rubbish  and  how  much  ashes  are  collected 
every  month?  What  is  the  average  amount  of  rubbish 
per  capita?  What  is  the  average  amount  of  ashes  per 
capita?  Determine  these  figures  in  each  case,  by  obtain- 
ing information  regarding  the  total  amount  and  the  num- 
ber of  people  from  whom  these  amounts  were  obtained, 
over  a  known  period  of  time. 

How  many  wagons  are  employed  for  collecting  rubbish? 
How  many  for  collecting  ashes?  What  is  the  ton-mileage 
for  each  form  of  refuse,  over  a  definite  period  ?  What  sort 
of  wagons  are  used  in  each  case?  What  is  the  capacity  of 
each  type  of  wagon?  Are  the  wagons  covered  during 
transit  to  the  final  place  of  disposal?  What  is  the  char- 
acter of  the  cover  employed  ?  Are  the  wagons  dust-tight  ? 
How  many  men  are  emplo^^ed  in  collecting  rubbish?  In 
collecting  ashes? 

What  method  is  employed  for  disposing  of  the  rubbish? 
For  disposing  of  the  ashes?  Ascertain  the  location  of  each 
place  where  rubbish  and  ashes  are  disposed  of  for  future 
inspection. 


METHODS  OF  GARBAGE   DISPOSAL  113 

Information  Desired  Concerning  Manure.  —  Is  any  pro- 
vision made  for  collection  and  disposal  of  manure?  If  so, 
describe  in  detail.  How  often  is  manure  collected?  Does 
the  community  have  an  ordinance  which  regulates  the 
keeping  of  manure?  If  so,  describe  it  in  detail.  Is  the 
ordinance  enforced  through  frequent  inspection?  Does  the 
ordinance  require  that  manure  shall  be  kept  in  a  closed 
container  having  an  impervious  bottom?  Is  the  manure 
treated  in  any  wa^^?     If  so,  describe  in  detail. 

How  often  is  the  manure  removed  from  the  premises? 
What  kind  of  vehicles  are  employed  for  this  purpose  ?  Is  the 
vehicle  covered  during  transit  ?  What  is  the  final  place  of 
disposal  ?  How  is  the  manure  disposed  of  ?  Describe  the 
method  in  detail.   How  much  manure  is  obtained  per  annum  ? 

Is  any  charge  made  for  collecting  the  manure?  Does 
the  city  receive  any  revenue  from  the  manure  ?  If  so,  how 
much?  Does  the  city  or  a  private  scavenger  remove  the 
manure?  If  a  private  scavenger  performs  the  service, 
what  is  the  arrangement  with  the  city?  If  a  charge  is 
made  for  collecting  the  manure,  what  is  the  charge?  If 
any  special  method  is  employed  in  collecting  and  disposing 
the  manure,  describe  that  method  in  detail. 

Data  from  Housing  Survey  should  be  Utilized  Here.  — 
During  the  housing  study  much  detailed  information  will 
be  secured  regarding  the  methods  employed  by  each  family 
in  disposing  of  its  garbage,  rubbish  and  ashes.  The  data 
obtained  in  that  study  can  be  included  in  this  chapter  and 
simply  referred  to  in  the  discussion  on  the  same  subjects  in 
the  chapter  on  housing.  If  the  surveyor  prefers  to  include 
the  data  in  the  chapter  on  housing  and  simply  refer  to  them 
in  the  presenc  chapter,  that  may  be  done.  In  either  case 
the  following  data  should  be  obtained  and  tabulated  in 
some  portion  of  the  report. 

Methods  of  Garbage  Disposal  Employed  by  the  People. 
—  What  is  the  number  and  percentage  of  houses  using  the 


114  COLLECTION  AND  DISPOSAL  OF  REFUSE 

public  scavenger  to  dispose  of  their  garbage  ?  What  is  the 
number  and  percentage  of  houses  where  the  garbage  is 
fed  to  animals  —  either  hogs,  chickens  or  any  other  ani- 
mals? What  is  the  number  and  percentage  of  houses 
where  the  garbage  is  locally  incinerated?  What  is  the 
number  and  percentage  of  houses  where  the  garbage  is 
allowed  to  rot  on  the  ground?  What  is  the  number  and 
percentage  of  houses  where  a  nuisance  due  to  improper 
garbage  disposal  was  found?  What  is  the  number  and 
percentage  of  houses  where  the  garbage-pail  was  found 
uncovered  ? 

Prevailing  Nuisances  Due  to  Faulty  Refuse  Disposal.  — 
In  addition,  the  survej^or  should  be  able  to  determine,  from 
this  house-to-house  study,  the  number  and  percentage  of 
houses  where  there  were  nuisances  due  to  accumulated  cans, 
bottles  and  similar  vessels,  and  w^here  manure  was  kept- on 
the  premises,  and  was  actively  breeding  flies.  During  his 
rounds  in  the  city,  and  during  the  special  housing  in- 
spection which  the  surveyor  will  make,  he  should 
ascertain  the  condition  of  the  alleys  and  the  streets,  so 
that  a  description  of  these  places  may  be  included  in  the 
report. 

Methods  of  Disposal.  —  The  disposal  of  refuse  consti- 
tutes a  serious  problem,  for  it  is  difficult  to  dispose  of  all 
forms  of  refuse  economically,  efficiently  and  without  creat- 
ing offensive  conditions.  Some  forms  of  refuse,  such  as 
ashes  and  ordinary  street  sweepings,  can  be  disposed  of 
quite  readily  and  effectively.  The  ashes  can  be  dumped 
or  used  for  filling  in  low  places,  and  the  street  sweepings 
can  be  disposed  of  in  a  similar  way.  If  the  street  sweep- 
ings contain  much  organic  matter,  they  should  be  thor- 
oughly mixed  with  ashes  or  earth  in  order  to  diminish  the 
nuisances  that  might  result. 

It  is  also  easy  to  dispose  of  rubbish  without  difficulty. 
The  rubbish,  after  it  is  collected,  is  frequently  sorted  in 


METHODS  OF  DISPOSAL 


115 


order  to  remove  the  things  that  have  economic  value,  such 
as  metals,  leather  and  similar  substances.  The  combus- 
tible material,  consisting  mostly  of  paper,  wood,  rags,  etc., 
can  be  readily  destroyed  by  incineration.  In  some  places, 
however,  after  the  valuable  things  are  removed  from  the 
rubbish,  the  remainder  is  dumped.  Care  should  be  taken 
in  such  cases  to  prevent  all  nuisances,  such  as  that  arising 
from  papers  which  are  allowed  to  blow  about. 


Fig.  29.     A  municipal  incinerator,  where  the  city's  refuse  and  dead 
animals  are  destroyed. 

It  is  in  the  disposal  of  organic  wastes,  such  as  garbage, 
dead  animals  and  slaughter-house  wastes  that  the  chief 
difficulties  are  found.  Animals  are  usually  destroyed  either 
by  burial,  incineration,  or  reduction.  The  same  processes 
may  be  employed  for  disposing  of  slaughter-house  wastes. 

The  methods  employed  for  disposing  of  garbage  are 
dumping  at  sea,  burial,  feeding  to  hogs,  incineration  and 
reduction.  The  dumping  of  garbage  on  the  land  results  in 
serious  nuisances,  and  should  be  prohibited  wherever  it  is 


110  COLLECTION  AND  DISPOSAL  OF  REFUSE 

practised.  There  are  also  serious  objections  to  disposing 
of  garbage  by  duni])ing  at  sea.  Very  frequently  the  gar- 
bage is  washed  back  on  to  the  beaches  along  the  coavSt, 
creating  conditions  which  are  very  offensive  and  which 
affect  the  value  of  the  beach  for  bathing  purposes.  More- 
over, the  disposal  of  garbage  by  that  method  is  a  total 
economic  loss. 

The  second  method  of  disposal  suggested,  namely  that  of 
burial,  can  undoubtedly  be  employed  without  producing 
offensive  conditions.  The  garbage  is  buried  by  alternating 
a  layer  of  garbage  with  a  layer  of  soil.  Certain  precautions, 
as  to  the  depth  of  the  layer  of  garbage  and  the  total  depth 
at  which  the  garbage  is  buried,  must  be  observed.  If  these 
precautions  are  taken,  the  garbage  wdll  in  time  be  decom- 
posed without  offense  and  will  also  increase  the  fertility  of 
the  soil.  The  process  is  a  slow  one,  however,  and  there  is 
no  economic  return  except  from  the  increased  soil  fertility. 

The  disposal  of  garbage  by  feeding  to  hogs  is  coming  into 
very  wide  use  and  is  meeting  with  much  favor.  The  uni- 
versal belief  that  hogs  are  filthy  animals  and  that  hog-pens 
can  never  be  kept  clean  is  breaking  down.  Both  hogs  and 
hog-pens  can  be  kept  clean,  so  that  the.  nuisances  from 
feeding  garbage  to  hogs  can  be  reduced  to  a  minimum. 
There  are  innumerable  small  cities  where  the  garbage  is 
disposed  of  in  this  way. 

The  feeding  of  garbage  to  hogs  is  desirable  for  several 
reasons.  In  thQ  first  place,  this  method  of  disposal  can 
be  conducted  so  that  no  nuisance  will  result.  Secondly,  a 
human  waste  product  is  transformed  by  this  method  into 
excellent  and  important  food,  thus  increasing  the  available 
food  supply  of  the  world.  Thirdly,  this  process  not  only 
makes  garbage-disposal  self-supporting,  but  actually  yields 
a  handsome  profit. 

There  are  many  cities  in  this  country  where  private  scaven- 
gers pay  the  city  for  the  privilege  of  removing  the  garbage 


METHODS  OF  DISPOSAL 


117 


in  order  that  they  may  feed  it  to  hogs.  It  has  been  sug- 
gested that  communities  having  a  population  of  100,000  or 
less  would  find  it  profitable  to  dispose  of  their  garbage  by 
feeding  it  to  hogs,  whereas  larger  communities  would  find 
it  more  profitable  to  treat  the  garbage  by  reduction.  With 
high  wages  and  excessive  costs  of  materials,  the  pendulum 
seems  to  be  swinging  toward  the  disposal  of  garbage  by 
feeding  to  hogs,  even  in  the  very  large  cities.  The  cities 
of  Worcester  and  Providence  have  long  been  utilizing  their 


Fig.  30.  A  view  of  an  unsatisfactory  piggery.  Both  garbage  and 
rubbish  are  damped  here,  and  the  hogs  pick  out  the  edible  from  the 
non-edible  material.  Literally  millions  of  flies  buzzed  about  the 
decomposing  organic  matter. 

garbage  in  this  way.  In  1916,  of  the  66  cities  estimated  at 
having  over  100,000  population,  20,  or  about  30  per  cent, 
were  disposing  of  their  garbage  by  feeding  to  hogs.  More 
recently,  Newark,  Baltimore  and  Washington  have  taken 
steps  to  introduce  this  method  of  garbage  disposal.  In 
Baltimore  55,000  tons  of  garbage  must  be  handled  every 
year.     It  is  estimated  that  this  amount  of  garbage  will 


118 


COLLECTION  AND  DISPOSAL  OF  REFUSE 


support  15,000  hogs,  and  that  the  annual  return  from  this 
method  of  disposal  will  be  $165,000  per  year.^ 

The  feeding  of  garbage  to  hogs  received  considerable 
impetus  during  the  war,  through  the  efforts  of  the  United 
States  Bureau  of  Food  Administration.  AVherc  garl^age  is 
fed  to  hogs,  it  is  important  to  remember  that  it  should  be 
free  from  all  forms  of  rubbish,  including  glass,  tin  cans, 
paper  and  other  inedible  materials.  The  garbage  should 
preferably  not  be  wrapped  in  paper,  as  the  disposal  of  the 
paper  later  creates  a  serious  problem.  In  order  to  protect 
the  hogs,  and  to  prevent  the  community  or  private  indi- 
vidual from  sustaining  heavy  financial  loss,  the  hogs  should 
be  given  the  hog-cholera  serum  and  vaccine  treatment. 


I'lu.  '61.  An  efficient  incinerator  in  Ardmore,  Okla.,  where  rubbish 
and  night  soil  are  destroyed. 

Garbage  can  also  be  incinerated  without  producing 
offensive  odors,  providing  the  temperature  of  incineration 

'  Since  this  was  written  Baltimore  has  discontinued  the  practice  of 
feeding  its  garbage  to  hogs,  as  the  garbage  would  often  be  too  decom- 
posed on  arrival  at  the  hog-farm. 


DUMPING   AT  SEA  119 

is  high  enough.  Otnerwise  the  incinerating  plant  will 
prove  to  be  a  serious  nuisance  and  will  cause  many  com- 
plaints from  nearby  residents.  The  dust  nuisance  from 
incinerators  is  not  due  to  the  temperature  of  operation,  but 
is  due  to  the  improper  design  and  operation  of  the  plant. 
Before  incinerating  refuse,  it  is  important  to  separate  the 
non-combustible  from  the  combustible  materials.  Al- 
though incineration  destroys  all  life  and  renders  the  gar- 
bage perfectly  harmless  and  free  from  danger,  the  process 
is  a  complete  loss.  Nothing  is  obtained  from  this  method 
of  disposal,  whereas  the  cost  of  fuel,  labor  and  maintenance 
is  considerable. 

Reduction  of  garbage  was  introduced  in  order  to  attempt 
to  make  garbage  disposal  profitable.  There  are  various 
patented  processes  employed,  but  all  aim  to  remove  the 
grease,  either  by  cooking  and  pressing,  or  by  treatment  with 
a  grease  solvent  such  as  naphtha.  The  grease  is  the  sub- 
stance that  has  commercial  value.  The  solid  matter  which 
is  left  behind  after  the  grease  is  removed  is  called  tankage 
and  is  used  for  fertilizer  purposes.  This  method  of  dis- 
posal is  frequently  offensive,  the  degree  of  the  nuisance 
depending  on  the  skill,  care  and  intelligence  with  which 
the  plant  is  operated. 

The  following  questions  concerning  each  process  will  help 
the  surveyor  to  ascertain  the  iiformation  he  desires. 

Dumping  at  Sea.  —  What  part  of  the  refuse  is  dumped 
at  sea?  How  many  scows  are  employed  for  this  purpose? 
What  is  the  capacity  of  the  scows  in  use?  How  often  are 
the  loaded  scows  taken  to  sea?  What  is  the  total  amount 
of  refuse  dumped  at  sea  in  a  given  period  of  time,  such  as  a 
week,  or  a  month,  or  a  year?  Is  any  attempt  made  to 
salvage  any  portion  of  the  refuse?  If  so,  what  materials 
are  salvaged?  What  is  the  usual  revenue  from  these  sub- 
stances in  a  given  period  of  time?  How  are  the  scows 
loaded?     Describe  in  detail.     How  far  off  shore  are  the 


120 


COLLECTION  AND  DLSPOSAL  OF  REFUSE 


scows  emptied  ?     What  nuisances,  if  any,  are  caused  by  this 
method  of  disposal? 

Dumping  on  Land.  —  What  portions  of  the  refuse  are 
dumped  on  the  land?  Ls  the  garbage  and  other  organic 
matter  disposed  of  in  this  way?  If  so,  describe  the  pro- 
cedure employed  and  the  nuisances  which  result  from  this 
method  of  disposal.  If  rubbish  and  ashes  alone  are  dumped, 
is  any  attempt  made  to  salvage  the  valuable  materials 
from  the  rubbish?  What  is  the  net  revenue  obtained 
from  this  source  in  a  given  period  of  time?  Where  is  the 
dump  located?  Is  the  land  used  being  filled  in  by  this 
method  of  disposal?  What  nuisances,  if  any,  result  from 
this  method  of  disposal? 


Fig.  32.  A  private  scavenger  emptying  his  load  at  a  burning  dump. 
These  places  are  usually  not  supervised  and  are  very  offensive. 

BuriaL  —  What  portion  of  the  refuse  is  disposed  of  by 
this  method?  Where  is  the  burial-ground  located?  What 
are  the  dimensions  of  the  trenches  employed  for  burying 
the  refuse?  What  depth  of  sand  is  employed  to  cover  the 
refuse?     How  long  is  the  refuse  buried  before  the  ground 


FEEDING  TO   HOGS 


121 


is  used  again  for  similar  purposes?  How  much  ground  is 
available  for  this  method  of  disposal?  What  nuisances,  if 
any,  result  from  this  method  of  disposal? 

Feeding  to  Hogs.  —  Is  the  garbage  collected  separately 
from  other  forms  of  refuse?  How  old  is  the  garbage  at 
the  time  of  collection  ?  How  old  is  the  garbage  at  the  time 
of  feeding?  Where  is  the  hog-farm  located?  How  many 
hogs  are  sustained  by  the  available  garbage? 


L*iV 


Fig.  33.  A  filthy,  unsightly  piggery,  swarming  with  flies  and  per- 
vaded with  foul  odors.  Where  garbage  is  fed  to  hogs,  it  is  important 
that  special  feeding  boards  be  employed  and  that  all  forms  of  rubbish 
should  be  excluded  from  the  organic  refuse. 

Are  the  hogs  treated  with  serum  and  vaccine  against 
hog-cholera?  Arenew  hogs  quarantined  before  they  are 
allowed  to  mingle  with  the  rest  of  the  herd  ?  What  is  the 
normal  annual  loss  in  hogs,  due  to  sickness  or  any  other 

cause  ? 

What  is  the  area  available  for  the  hog-farm  ?  How  often 
during  the  day  are  the  hogs  fed?  Are  feeding-boards 
available  for  the  feedings?     If  so,  of  what  material  are  the 


122  COLLECTION  AND  DLSPOSAL  OF  REFUSE 

feeding-boards  made?  How  often  are  the  feeding-boards 
cleaned?  What  method  of  cleaning  is  employed?  If 
feeding-boards  are  not  used,  what  other  method  of  feeding 
is  employed?     Describe  in  detail. 

What  precautions  are  taken  to  keep  the  pens  used  by 
the  hogs  in  a  clean  and  satisfactory  condition  ?  What  other 
facilities  are  available  to  keep  the  hogs  clean  and  comfort- 
able? 

What  is  the  average  number  of  hogs  sold  during  the  year  ? 
What  is  the  normal  revenue  derived  from  this  source  ?  If  a 
municipal  piggery,  what  is  the  net  income  to  the  city  from 
this  method  of  disposal? 

How  is  the  residue  from  the  hog  feedings  disposed? 
What  nuisances,  if  any,  result  from  this  method  of  disposal  ? 

Incinerator.  —  AVhat  portions  of  the  refuse  are  disposed 
of  by  this  method?  W^hen  was  the  incinerator  built? 
Where  is  it  located  ?  What  was  the  cost  of  the  structure  ? 
Has  it  been  giving  satisfactory  service  since  its  construc- 
tion? If  not,  state  the  reasons  in  detail.  How  much 
refuse  can  the  incinerator  destroy  in  a  day?  Is  the  non- 
combustible  material  separated  from  the  combustible,  be- 
fore the  refuse  is  incinerated?  How  much  refuse  is  incin- 
erated per  day?  Are  dead  animals  destroyed  by  the  same 
process?  Are  the  contents  of  privies  destroyed  by  in- 
cineration ? 

How  many  units  are  available  ?  What  is  the  capacity  of 
each?  What  is  the  source  of  the  heat  employed?  Where 
does  the  refuse  enter  the  incinerator?  How  many  times 
during  the  day  is  the  incinerator  fed  with  refuse?  De- 
scribe in  detail  the  method  of  operation  of  the  incinerator. 
What  is  the  temperature  of  incineration  employed  ?  Is  the 
incinerator  sufficiently  large  to  meet  the  requirements  of 
the  city? 

Is  the  incinerator  under  efficient  control  and  supervision  ? 
How  many  men  are  employed  at  the  plant?     Are  satis- 


REDUCTION 


123 


factory  and  adequate  toilet  and  washing  facilities  available 
for  the  men?  How  are  the  ashes  and  residue,  resulting 
from  incineration,  disposed  of?  What  nuisances,  if  any, 
result  from  this  method  of  disposal  ? 


Fig.  34.  The  municipal  incinerator  in  a  town  of  15,000  inhabitants 
which  lay  idle  while  the  disposal  of  refuse  was  creating  serious  nuisances. 

Reduction.  —  Is  the  garbage  free  from  other  forms  of 
refuse  at  the  time  it  is  collected?  How  is  the  garbage 
brought  to  the  reduction  plant?  Where  is  the  reduction 
plant  located?  What  is  the  capacity  of  the  reduction 
plant  ?  When  was  it  built  ?  Is  it  operated  under  munici- 
pal or  private  auspices?  If  the  latter,  what  is  the  name 
of  the  company  ?  What  method  of  reduction  is  employed  ? 
Describe  the  process  in  detail. 

How  much  garbage  is  treated  by  this  method  every  day  ? 
Is  the  reduction  plant  adequate  to  meet  the  requirements 
of  the  city?  What  reagent,  if  any,  is  used  as  an  extractive? 
What  is  the  total  yield  of  grease  in  a  given  period  of  time  ? 
How  much  revenue  does  this  produce? 

How  much  tankage  is  obtained  from  this  process  in  a 


124  COLLECTION  AND  DISPOSAL  OF  REFUSE 

given  period  of  time  ?     How  is  the  tankage  finally  disposed 
of?     What  revenue,  if  anj^,  is  derived  from  this  source? 

How  many  men  are  employed  at  the  plant  ?  Is  the  plant 
under  efficient  control  and  supervision  ?  Are  adequate  and 
satisfactory  toilet  and  washing  facilities  available  at  the 
plant  ?  If  the  reduction  plant  is  municipally  owned,  what 
is  the  net  revenue  obtained  from  this  method  of  garbage 
disposal  ?  What  nuisances,  if  any,  result  from  this  method 
of  disposal  ? 


OUTLINE   OF   CHAPTER   ON   COLLECTION   AND   DISPOSAL 

OF  REFUSE 

1.  Necessity  and  desirability  of  removing  solid  wastes. 

2.  Frequency  of  collection.  By  whom  is  this  service  performed  and 
on  what  basis?  Revenue  to  the  city;  wagons  employed;  men  em- 
ployed; charge  for  service;  place  of  disposal;  method  of  disposal; 
combined  or  separate  method  of  collection. 

3.  Same  details  for  collection  of  refuse.  —  Dumps;  incinerator; 
personnel  of  these  establishments;   inspection  of  piggeries. 

4.  Results  of  house-to-house  canvas. 
Number  and  percentage  using  public  scavenger. 
Number  and  percentage  feeding  to  animals. 
Number  and  percentage  disposing  by  burning. 

Number  and  percentage  disposing  by  depositing  on  ground. 
Number  and  percentage  of  nuisances  resulting. 
Number  and  percentage  using  uncovered  garbage-pails. 

5.  Nuisances  due  to  empty  cans,  dirty  alleys,  etc. 

6.  Disposal  of  manure;   fly-breeding-places. 

7.  Photographs. 

8.  Summary. 

9.  Recommendations. 


CHAPTER  VIII 
MILK-SUPPLY 

Milk  is  One  of  the  Most  Important  Foods  of  Mankind. 

—  The  milk-supply  is  probably  the  most  important  food- 
supply  in  a  community,  since  milk  and  milk-products  are 
used,  to  some  extent,  by  everybody.  Infants  are  frequently 
dependent  on  the  public  milk-supply  for  their  very  life, 
and  many  young  children  are  similarly  dependent.  The 
importance  of  milk  as  a  food  is  determined  by  various 
factors.  In  the  first  place  it  is  one  of  the  best-balanced 
foods,  containing  carbohydrates,  fats,  proteins  and  mineral 
salts  in  proper  amounts.  In  the  second  place,  it  is  one  of 
the  most  readily  digestible  foods,  and  is  therefore  invalu- 
able to  infants  and  children,  and  to  the  aged,  the  weak  and 
the  sick.  In  the  third  place,  it  is  one  of  the  best  growth- 
promoting  foods,  containing  the  vitamines  necessary  for 
a  complete  diet  and  also  for  promoting  growth.  Finally, 
it  apparently  possesses  the  quality  of  inhibiting  auto- 
intoxication in  the  intestinal  canal. 

A  Safe  Milk-Supply  Essential  to  the  Public  Health.  — 
For  all  these  reasons,  it  is  obvious  that  milk  is  one  of  the 
best  and  most  important  sources  of  food  in  a  community. 
Dr.  Raymond  Pearl  has  recently  stated  ^  that  the  most 
important  sources  of  human  food  are  wheat,  the  hog,  and 
the  dairy  cow.  These  three  together  produce  62  per  cent 
of  all  the  proteins  and  carbohydrates  used  as  human  food, 
69  per  cent  of  all  the  fat,  and  65  per  cent  of  all  the  calories. 
Unfortunately,    however,    milk   is    an   excellent   food   for 

1  Raymond  Pearl,  The  Nation's  Food.    Saunders  &  Co.,  Phila.,  1920. 

125 


126  MILK-SUPPLY 

bacteria  as  well  as  for  human  beings,  and,  under  favor- 
able conditions,  these  minute  organisms  multiply  in  it 
with  great  rapidity.  *  Not  only  may  excessively  large  num- 
bers of  bacteria  in  milk-prove  injurious  to  infants,  children 
and  adults,  but,  if  the  milk-supply  is  infected  with  specific 
germs  of  disease,  it  may  become  responsible  for  epidemics. 
Outbreaks  of  typhoid  fever,  diphtheria,  scarlet  fever,  and 
septic  sore  throat  have  frequently  been  traced  to  infected 
milk  supplies.  The  relationship  of  poor  or  dirty  milk  to 
infant  diarrhea  and  infant  deaths  is  only  too  well  known. 
It  is  also  true  that  tuberculosis  may  be  transmitted  to 
infants  and  children  if  they  are  fed  with  milk  obtained  from 
tuberculous  cows.  The  close  relationship  between  the 
milk-supply  and  the  public  health  is  reahzed  by  most  public 
health  workers,  but  most  laymen  are  either  ignorant  or 
careless  in  regard  to  it.  A  safe  milk-supply  in  a  com- 
munity is  almost  as  important  as  a  safe  water-supply. 

"  Perfect  Pasteurization  "  is  the  Best  Way  to  Safeguard 
the  Milk-Supply.  —  One  of  the  greatest  boons  conferred 
upon  mankind  was  the  introduction  of  pasteurization  for 
milk.  This  process  was  in  use  for  some  time  before  a 
perfect  method  was  developed.  The  flash  method,  which 
was  the  first  to  be  employed,  not  only  failed  to  destroy 
the  bacteria  in  sufficient  numbers,  but  by  employing  a 
very  high  temperature  brought  about  certain  undesirable 
chemical  changes  in  the  milk.  Digestion  of  the  milk  was 
made  more  difficult,  and  the  enzymes  were  destroyed. 
Sometimes  the  sugar  was  charred  and  the  milk  had  a  burnt 
taste.  As  a  result,  pasteurization  came  into  disrepute  and 
was  not  practised  as  extensively  as  it  should  have  been. 
With  the  introduction  of  the  "perfect  "  method  of  pasteuri- 
zation, by  which  the  milk  is  heated  to  145°  F.,  maintained 
at  that  temperature  for  twenty  to  thirty  minutes,  and  then 
cooled  rapidly  and  kept  cold,  pasteurization  came  into 
great  favor,  for  the  new  process  was  free  from  the  bad 


PERFECT  PASTEURIZATION 


127 


features  of  the  flash  method  of  pasteurization,  and  made 
the  milk  perfectly  safe.  The  use  of  pasteurized  milk  has 
doubtless  saved  the  lives  of  thousands  of  infants,  children 
and  adults.  No  matter  how  clean  and  pure  a  milk-supply 
is,  it  is  never  definitely  safe,  unless  it  has  been  satisfactorily 
pasteurized.  Some  milk  companies  have  persistently  re- 
fused to  pasteurize  their  milk,  contending  that  the  milk 


Fig.  35.  A  clean,  light  and  thoroughly  ventilated  milk  room  in 
Tulsa,  Okla.,  showing  special  racks  where  the  bottles  are  inverted,  a 
separator,  and  a  pasteurizing  machine. 


was  being  produced  under  ideal  conditions,  until  an  epi- 
demic of  disease  traced  to  their  supplies  has  driven  them 
to  seek  safety  in  pasteurization.  The  milk  may  be  pro- 
duced in  a  clean  barn  from  healthy,  inspected  cows,  under 
conditions  where  every  precaution  with  regard  to  sterility, 
cleanliness,  and  freedom  from  flies  is  observed,  where  the 
employees  are  required  to  pass  medical  examinations  at 
regular  intervals,  where  the  milk  is  cooled  immediately, 
kept  cold,  and  delivered  within  twenty-four  hours  after 


128  MILK-SUPPLY 

it  is  produced,  and  where  the  condition  of  the  milk-supply 
is  controlled  by  bacteriological  tests  —  and  even  under 
these  excellent  and  unusual  conditions  the  milk-supply 
may  not  be  safe,  if  pasteurization  is  not  employed.  Where 
pasteurized  milk  has  been  responsible  for  disease  and 
death,  the  fault  has  not  been  with  the  ''perfect"  process 
of  pasteurization,  but  has  been  due  either  to  faulty  pas- 
teurization, or  else  to  the  introduction  of  infectious  material 
after  the  milk  has  been  pasteurized.  Where  pasteuriza- 
tion is  employed  it  must  be  conducted  intelligently,  care- 
fully, and  under  trained  supervision;  otherwise  it  simply 
becomes  a  name  and  a  desired  goal,  and  not  a  means  of 
safeguarding  the  public  health. 

Health  Surveyor  should  Study  the  Milk-Supply  Per- 
sonally. —  The  milk-supply  is  naturally  one  of  the  factors 
to  be  considered  in  a  public  health  survey.  It  is  im- 
portant, however,  that  the  study  of  the  milk-supply  should 
be  a  personal  investigation,  and  not  merely  a  record  of 
some  other  person's  scorings  and  laboratory  examinations. 
The  health  surveyor  himself,  or  one  of  his  assistants, 
should  stud}'  the  milk  ordinance,  inspect  as  many  dairies 
and  distributing  stations  as  possible,  and  finally  collect 
and  examine  numerous  samples  of  milk,  both  chemically 
and  bacteriologically.  It  is  only  in  this  way  that  a 
thorough  knowledge  of  the  milk-supply  can  be  obtained. 

The  surveyor  should  arrange  to  meet  the  milk  inspector 
or  any  other  official  who  has  charge  of  the  milk-supply. 
If  a  copy  of  the  milk  ordinance  has  not  been  obtained 
before,  it  should  be  obtained  from  this  official,  and  ex- 
amined carefully  in  order  to  determine  whether  or  not  it 
is  complete  and  up-to-date.  Usually  the  ordinance  of  one 
city  is  based  on  that  which  is  being  used  by  another. 
Sometimes  a  city  of  10,000  or  25,000  adopts,  without 
change,  the  ordinance  which  is  in  use  in  a  large  metropolis, 
without  realizing  that  the  conditions  for  the  two  cities  are 


REGARDING  THE   MILK   ORDINANCE 


129 


different,  and  that  some  of  the  regulations  should  be 
modified. 

Information  Regarding  the  Milk  Ordinance.  —  In  study- 
ing the  milk  ordinance,  the  surveyor  should  observe  the 
following  points  in  particular. 

Does  the  ordinance  require  that  the  cows  shall  be  tuber- 
culin tested  by  a  reliable  person  at  least  once  every  year? 
Does  it  say  anything  about  the  sterilization  of  utensils 
used  in  producing  and  handling  milk?  Does  it  say  any- 
thing about  the  rapid  cooling  of  milk  and  the  importance 
of  keeping  milk  cold  until  it  is  delivered?  Does  it  say  any- 
thing about  the  cleanliness  of  the  places  where  milk  is 


Fig.  36.  The  model  cow  barn  at  the  farm  above,  where  each  cow 
has  an  individual  drinking  cup  and  plenty  of  fresh  air  and  light.  The 
manure  is  removed  frequently  so  that  the  barn  is  always  clean. 

produced?  Does  it  require  milk-producers  and  milk- 
handlers  to  be  free  from  disease,  as  shown  by  a  thorough 
medical  examination  including  laboratory  tests?  Does  it 
define  pasteurization?  What  milk  must  be  pasteurized, 
according  to  the  ordinance?     Does  it  attempt  to  grade 


130  MILK-SUPPLY 

the  quality  of  the  milk?  If  so,  on  what  basis  is  this  done? 
What  are  the  chemical  standards  required  by  the  milk 
ordinance?  What  are  the  bacteriological  standards? 
What  is  the  minimum  score  that  a  dairy  must  obtain 
in  order  to  pass  inspection? 

The  above  information  can  be  obtained  by  studying  the 
milk  ordinance.  Any  matter  which  is  not  clear  can 
usually  be  explained  by  the  milk  inspector. 

Information  Concerning  the  Production,  Handling  and 
Delivery  of  Milk.  —  The  following  information  should  be 
obtained  from  the  milk  inspector. 

How  many 'producers  supply  milk  to  the  city?  What  is 
the  distribution  of  these  dairy-farms?  What  is  the 
greatest  distance  from  which  milk  is  brought  to  the  city? 
Is  milk  brought  to  the  city  twice  a  day?  How  is  the 
milk  carried  —  by  wagon,  motor  truck,  interurban  trolley, 
steam  railroad,  or  water?  How  much  of  the  supply  is 
carried  ])y  each  method?  What  amount  and  what  pro- 
portion of  the  city's  milk-supply  are  furnished  by  the 
wholesale  distributors?  What  amount  and  w^hat  propor- 
tion of  the  city's  milk-supply  are  delivered  by  the  producers 
themselves?  How  often  are  retail  deliveries  made? 
What  is  the  cost  of  the  various  grades  of  milk  sold  in  the 

city? 

How  many  one  and  two-cow  dairies  exist  in  the  city? 
Are  these  subject  to  the  same  regulations  as  the  larger 
dairies?     Are  they  inspected  as  frequently? 

What  proportion  of  the  milk-supply  is  pasteurized? 
Are  the  small  distributors,  as  well  as  the  wholesale  ones, 
required  to  pasteurize  the  milk? 

How  often  are  the  dairies  inspected?  If  available, 
obtain  a  copy  of  the  score-card  employed,  and  also  the 
results  of  the  most  recent  inspection.  The  score-card 
should  be  criticized  if  it  does  not  conform  to  the  best 
standards. 


SURVEYOR  SHOULD  INSPECT  THE   DAIRIES       131 

Is  the  milk-supply  controlled  by  laboratory  tests? 
What  tests  are  made?  Is  the  laboratorian  sufficiently 
trained  to  perform  these  tests?  Who  interprets  the 
results?  Is  he  sufficiently  trained  to  perform  this  work 
satisfactorily?  How  often  are  these  tests  made?  Obtain, 
if  possible,  a  list  of  results  of  laboratory  tests  performed  on 
various  samples  of  milk. 


Fig.  37.  Exterior  view  of  a  model  cow  barn  in  Ardmore,  Okla.,  also 
i3howing  part  of  the  silo.  The  screened  door  is  the  entrance  to  the  milk 
room,  where  the  milk  is  strained  and  cooled. 

Health  Surveyor  should  Inspect  the  Dairies.  —  After 
this  information  has  been  obtained  from  the  milk  inspector, 
the  surveyor  should  arrange  to  inspect  the  dairies.  It  is 
desirable,  in  order  to  save  time,  for  him  to  be  accompanied 
by  somebody  who  knows  where  the  dairies  are  located.  A 
conveyance  can  usually  be  procured  from  the  city,  usually 
from  the  milk  inspector  himself.  There  are  numerous 
cities  where  milk  inspectors  are  not  employed,  and  others 
where  the  inspectors  are  inefficient  and  know  very  little 
about  the  dairies,  the  number  delivering  milk  in  the  city, 


132 


MILK-SUPPLY 


and  the  location  of  the  dairy-farms.  In  such  cases,  the 
surveyor  will  have  to  seek  aid  from  other  sources.  In 
one  city,  the  author  was  aided  in  his  search  for  the  dairy- 
farms  by  an  ice-cream  dealer;  in  another  city,  by  one  of 
the  wholesale  milk-distributors;  in  a  third  city  by  a  private 
veterinarian;  and  in  still  another,  b}^  a  private  citizen  who 
knew  where  the  dairies  were  located.  In  every  city, 
there  is  at  least  one  person  who  knows  where  the  dairies 
are  located,  and  it  is  usually  possible  to  obtain  the  aid  of 
this  person  in  making  the  inspection. 


Fig.  38.  Interior  view  of  the  model  cow  barn  at  Ardniore,  Okla. 
The  barn  is  clean,  well  lighted,  and  well  ventilated. 

Where  a  milk  inspector  is  employed  by  the  city,  the 
need  of  help  from  other  sources  is  usually  not  necessary. 
The  milk  inspector  generalh'  knows  where  the  dairies  are 
located  and  has  a  conveyance  which  can  be  used  for  the 
inspections.  He  is  usually  glad  to  accompany  the.  sur- 
veyor, to  see  how  he  performs  the  inspections,  and  to 
compare  the  results  obtained  with  those  of  his  own  in- 
spections. 


SURVEYOR   SHOULD   INSPECT   THE   DAIRIES       133 

Where  the  city  has  a  population  of  100,000  or  more,  it 
will  usually  be  impossible  to  inspect  all  the  dairies  from 
which  milk  is  brought  to  the  city,  owing  to  the  great  dis- 
tances from  which  some  of  the  milk  is  brought  and  because 
of  the  limited  time  available  for  the  survey.  It  is  usually 
possible,  however,  to  visit  every  dairy  within  a  radius  of 
20  to  25  miles,  and  these  at  least  can  be  inspected  and 
scored.  If  there  are  some  dairies  which  cannot  be  in- 
spected, the  surveyor  should  at  least  obtain  samples  of 
their  milk  as  it  arrives  in  the  city  and  examine  it  for  tem- 
perature on  arrival,  besides  performing  the  regular  chemi- 
cal and  bacteriological  tests.  In  this  way,  some  knowl- 
edge of  the  entire  milk-supply  can  be  obtained. 

The  author  has  found  the  following  score-card  of  con- 
siderable value  in  performing  the  dairy  inspections.  It  is 
but  a  slight  modification  of  Dr.  C.  E.  North's  score-card 
and  is  simple  and  easy  to  fill  out.  The  important  items 
that  are  to  be  considered  in  dairy  inspection  are  plainly 
shown  on  this  card.  The  total  score  obtained  by  each 
dairy  can  be  enumerated  on  the  card,  and,  when  the 
inspections  have  been  completed,  the  results  of  all  can  be 
tabulated  in  the  manner  outlined  below. 


134 


MILK-SUPPLY 


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136 


MILK-SUPPLY 


TABLE  5 

RESULTS  OF  DAIRY  INSPECTIONS,   SHOWING  THE  SCORE- 
CARD  RATINGS,  ARRANGED  ACCORDING  TO  SCORE 


Name  of 
producer. 

Quarts  of 
milk  sold 
per  day. 

Primary 
methods. 

Equip- 
ment. 

Secondary 

methods 

and 

equipment. 

Total 
score. 

Date  of 

last 

tuberculin 

test. 

CLASSIFICATION   OF   DAIRIES 


137 


Not  only  is  it  possible  to  arrange  the  dairies  according 
to  their  score-card  rating,  but  it  is  also  possible  to  form 
another  table,  in  which  the  dairies  that  were  inspected 
are  placed  in  different  groups  according  to  the  rating  which 
each  has  obtained.  This  table  has  considerable  value  in 
determining  at  a  glance  the  condition  of  most  of  the  dairies. 
An  outline  of  the  table  is  given  below. 


TABLE  6 

CLASSIFICATION    OF  DAIRIES  ACCORDING  TO  SCORE-CARD 

RATINGS 


Rating. 

Number  of 
dairies. 

Per  cent  of  num- 
ber inspected. 

Between  90-100  per  cent 

Between  80-90  per  cent 

Between  70-80  per  cent 

Between  60-70  per  cent 

Between  50-60  per  cent 

Between  40-50  per  cent 

Between  30-40  per  cent 

Between  20-30  per  cent 

Total  Number 

Above  60  per  cent .' . 

Below  60  per  cent 

It  is,  of  course,  necessary  to  require  a  certain  rating  as 
the  minimum  necessary  for  a  passing  grade.  The  actual 
per  cent  varies  in  different  localities;  but  a  conservative 
standard  for  most  communities  is  60  per  cent.  Where 
there  has  already  been  much  agitation  about  the  milk- 
supply,  together  with  education  along  this  line  and  fre- 
quent inspections,  the  minimum  standard  may  be  higher 
than  that  suggested  here.     In  spite  of  that,  however,  the 


138 


MlLK-SUPtLY 


surveyor   should   assume    the   minimum   rating   necessary 
for  passing  to  be  60  per  cent. 

The  mere  recording  of  the  score-card  ratings,  however, 
will  not  give  the  people  a  clear  and  definite  idea  of  the 
shortcomings  or  evils  that  were  found  during  the  survey. 
It  is  therefore  important  to  include,  in  the  final  report,  a 
discussion  of  the  findings. 


Fig.  39.  An  open  shed  in  the  Southwest  where  milk  is  produced. 
There  is  no  protection  against  dust,  flies  or  other  objectionable  things. 
Adjoining  the  shed  is  the  stable.  These  conditions  are  unfavorable  to 
the  production  of  clean  niilk. 

Distributing  Dairies  should  also  be  Inspected.  —  After 
the  dairies  have  been  inspected  and  scored,  the  surveyor 
should  arrange  to  visit  the  large  distributing  dairies  in  the 
city.  From  these  inspections  the  answers  to  the  following 
questions  should  be  obtained. 

What  is  the  name  of  the  dairy?  How  much  milk  is 
handled  per  day?  How  many  producers  deliver  milk  to 
this  dairy?  How  often  during  the  day  does  the  milk 
arrive?     How  is  the  milk  shipped?     What  is  the  greatest 


DISTRIBUTING  DAIRIES  SHOULD   BE   INSPECTED      139 

distance  from  which  milk  is  brought  to  this  dairy?  What 
is  the  general  location  of  the  producing  dairies  that  deliver 
their  milk  to  the  distributing  dairy?  How  long  does  it 
take  for  the  milk  to  arrive  from  the  most  distant  dairy? 
What  is  the  average  time  required?  How  old  is  the  milk 
on  arrival?  Is  the  milk  iced  during  transit?  Is  the  milk 
strained  after  arrival? 

How  many  men  are  employed  in  handling  the  milk? 
Are  the  employees  free  from  disease,  as  demonstrated  by 
a  thorough  medical  examination,  including  laboratory 
tests? 


Fig.  40.  Another  open  shed  where  milk  is  produced  for  consump>- 
tion  in  the  city.  Wide-mouth  milk  pails  were  used.  Clouds  of  dust 
could  be  seen  entering  the  pail  during  the  milking.  Under  such  condi- 
tions milk  is  readily  contaminated. 


Is  the  milk  pasteurized?  What  method  of  pasteuriza- 
tion is  employed?  Is  the  milk  constantly  stirred  during 
pasteurization?  Is  the  pasteurizer  connected  with  an 
automatic  time  and  temperature  recording  device?  If  so, 
examine  carefully  and  determine  the  time  and  tempera- 


140 


MILK-SUPPLY 


ture  normally  employed.  If  not,  take  the  temperature  of 
the  milk  during  pasteurization,  and  ascertain,  from  the 
superintendent,  the  time  emploj-ed.  To  what  tempera- 
ture is  the  pasteurized  milk  cooled?  How  is  the  cooling 
performed  ?  What  time  is  required  for  cooling  ?  Determine 
by  special  test  the  temperature  of  the  milk  after  it  is  cooled. 
Is  the  milk  sold  in  bulk  or  in  bottles  ?  How  is  the  milk 
bottled  and  capped?  Are  automatic  devices  used  in  these 
processes  ? 


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Fig.  4L     A  simple  device  for  sterilizing  milk  bottles  with  steam. 


Where  is  the  milk  stored  before  delivery?  Is  the  stor- 
age room  ample?  What  is  the  temperature  of  the  storage 
room?  Is  the  temperature  sufficiently  low?  A  tempera- 
ture of  50°  F.,  or  less,  should  be  considered  satisfactory. 
How  long  is  the  milk  stored  before  it  is  delivered  to  the 
consumer? 

Are  facilities  available  for  cleaning  and  sterilizing  the 
bottles,  cans,  and  apparatus?  What  method  of  steriliza- 
tion is  employed?  Are  the  cleaning  and  sterilization 
considered  satisfactory? 


DISTRIBUTING  DAIRIES  SHOULD  BE  INSPECTED  .  141 

In  some  places  the  bottles  are  not  sterilized.  Where 
this  is  so,  the  surveyor  should  made  a  record  of  the  fact. 
Sometimes  the  cans  are  sterilized  by  inversion  over  a  jet 
of  live  steam.  It  is  important  to  remember,  however, 
that  if  the  exposure  of  the  can  to  the  live  steam  lasts  only 
for  a  few  seconds,  the  sterilization  will  probably  be  inade- 
quate.    Usually  several  minutes'   exposure  to  live  steam 


Fig.  42.  At  this  farm  the  milk  bottles  were  sterihzed  in  boiling 
water.  It  is  not  necessary  to  have  expensive  equipment  in  order  to 
produce  a  clean,  safe  milk. 

will  insure  sterility.  In  some  cases  the  plants  may  be 
found  to  be  using  a  commercial  product,  such  as  the 
hypochlorite  of  sodium  or  lime,  in  order  to  sterilize  the 
bottles  and  the  cans.  This  practice  is  undesirable  and 
should  be  condemned.  As  a  rule,  small  amounts  of  the 
disinfectant  are  left  behind  in  the  bottles  or  in  the  cans, 
and  tend  to  keep  the  milk  sweet  for  a  longer  period  of 
time,  in  spite  of  the  dirt  and  bacteria  which  may  have 
originally  been  present.  The  use  of  chemical  disinfectants 
for  sterilizing  milk-utensils  is  undesirable  and  should  be 


142  MILK-SUPPLY 

condemned,  because  it  tends  to  take  the  place  of  cleanli- 
ness and  care  in  the  production  and  handling  of  milk. 

The  following  questions  will  bring  out  the  additional 
information  which  the  surveyor  should  obtain. 

Is  the  plant  thoroughly  screened?  Is  it  light  and  airy, 
and  large  enough  for  the  amount  of  milk  handled?  Are 
toilet  facilities  readily  available  and  satisfactorily  main- 
tained? Are  washing  facilities  available  and  satisfactory? 
Are  cloak-rooms  or  special  clothing-lockers  provided?  Is 
the  floor  of  the  plant  made  of  impervious  material?  Does 
the  floor  drain  into  a  sewer? 

The  Surveyor  should  Arrange  to  Collect  Milk  Samples 
for   Analysis.  —  When    these    inspections    are    completed, 
the  surveyor  will  inform  the  plant  superintendents  of  his 
plan  to   collect  samples   of   milk  from   the   cans  as  they 
arrive  at  the  plant.     It  is  not  advisable  to  mention  the 
exact   day   when   the   samples   will    be    collected.     In  the 
meantime,  the  surveyor  should  provide  himself  with  a  ther- 
mometer and  a  lactometer  and  also  with  enough  sterile 
bottles   to    collect    samples    for    bacteriological    analyses. 
Some  arrangement  should   be  made  whereby  the  bottles 
can  be  iced  immediately  after  filling,  and  kept  cold.     If 
special  containers  for   icing  samples   are   not  obtainable, 
the  surveyor  can  procure  a  pail,  fill  it  with  cracked  ice, 
and  pack  the  milk  samples  in  the  ice,  until  they  can  be 
analyzed.     Enough    media,    sterile    pipettes,    sterile   Petri 
dishes  and  sterile  dilution  waters  should  be  on  hand  for 
the  bacteriological  analyses.     Early  in  the  morning,  the 
surveyor  or  his  assistant  should  arrive  at  one  of  the  dis- 
tributing stations  with  his  sample  bottles,  ready  to  collect 
samples  of  milk  from  the  cans  as  they  arrive.     It  is  desir- 
able to  have  assistants  collect  samples  of  milk  at  the  other 
distributing  dairies  at  the  same  time.     Otherwise  the  sur- 
veyor will  have  to  arrange  to  collect  the  samples  from 
the  other  dairies  on   different  days,  as  the  milk  usually 


COLLECT   MILK  SAMPLES  FOR  ANALYSIS         143 

arrives  in  the  morning;  and  while  the  surveyor  is  collect- 
ing his  samples  at  one  place,  milk  will  also  be  arriving  at 
the  other  dairies. 


Fig.  43.  A  millv  producer  standing  alongside  of  the  manure-pile  at 
the  rear  of  his  barn.  The  cows  are  milked  twice  a  day  in  this  barn  under 
very  unsatisfactor}"  conditions.  The  manure-pile  serves  as  an  excellent 
breeding-place  for  flies,  which  often  find  their  way  into  the  milk  pail. 


Two  sets  of  samples  should  be  collected,  one  for  a  bac- 
teriological examination,  and  the  other  for  a  chemical 
examination.  The  bacteriological  sample  must  be  col- 
lected under  aseptic  conditions  and  must  be  kept  cold 
until  the  analyses  are  made.  The  chemical  samples  may 
be  collected  in  clean  half-pint  or  pint  bottles,  which  can 
usually  be  borrowed  from  the  plant  where  the  samples 
are  being  obtained.  This  sample  should  preferably  be 
iced  and  should  be  analyzed  later  for  specific  gravity  and 
butter-fat.  If  the  surveyor  does  not  possess  a  lactometer, 
he  will  usually  succeed  in  borrowing  one,  either  from  the 


144  MILK-SUPPLY 

local  health  department  or  from  one  of  the  large  distribut- 
ing dairies.  If  a  lactometer  cannot  be  obtained  from  these 
sources,  one  may  possibly  be  obtained  from  a  private 
laboratory  in  the  city,  from  an  ice-cream  plant,  or  from 
the  state  health  department.  Facilities  for  making  the 
Babcock  test  for  butter-fat  will  usually  also  be  found  at 
one  of  these  places. 


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Fig.  44.  Another  cow  l)arn  showing  a  large  heap  of  manure  outside. 
FHes  can  very  easily  find  their  way  from  here  to  the  milk  pail. 

In  collecting  the  bacteriological  samples,  one  of  the  two 
methods  outlined  below  may  be  employed.  The  surveyor 
may  have  a  series  of  long,  sterile  tu])os  which  can  be  used 
for  collecting  the  sample,  or  he  may  borrow  a  milk-dipper, 
which  has  been  thoroughly  washed  and  cleaned  at  the 
plant  where  the  samples  are  being  collected.  A  can  of 
boiling  water  may  be  obtained,  and  the  dipper  sterilized. 
As  soon  as  the  water  becomes  cool,  it  must  be  replaced 
by  frosh,  boiling  water,  in  order  to  insure  the  sterility  of 
the  dipper. 

As  the  cans  of  milk  arrive,  the  milk  in  each  can  should 


COLLECT  MILK  SAMPLES  FOR  ANALYSIS         145 

be  thoroughly  stirred  with  the  dipper,  and  a  sample  of 
each  should  be  introduced  into  the  sterile  bottle  used  for 
the  bacteriological  sample.  In  this  way  a  composite 
sample  of  the  milk  can  be  obtained.  The  bottle  should, 
of  course,  be  marked  so  as  to  identify  the  milk.  After 
the  bottle  is  filled,  it  should  be  immediately  iced  and  kept 
cold.  The  temperature  of  the  milk  in  each  can  should 
then  be  taken  and  recorded  as  the  "  temperature  on  arrival." 
This  temperature  will  indicate  whether  or  not  the  milk 
has  bean  iced  in  transit.  After  the  temperature  of  each 
can  has  been  taken,  the  sample  for  the  chemical  analysis 
should  be  made  up  as  a  composite  of  samples  taken  from 
each  can,  and  should  be  iced  until  examined.  The  samples 
should  be  analyzed  both  chemically  and  bacteriologically, 
as  soon  after  they  are  collected  as  possible. 

Most  of  the  samples  which  have  been  collected  thus  far 
have  been  obtained  from  milk  which  is  shipped  into  the 
city.  It  is  also  important  to  collect  samples  of  the  milk 
which  is  delivered  by  the  producers  themselves.  In  order 
to  obtain  these  samples  it  will  be  necessary  to  tour  the  city 
during  the  early  morning,  while  the  milk-men  are  making 
their  deliveries.  A  pint-bottle  sample  should  be  obtained 
from  each  dealer.  If  pints  are  not  available,  a  quart 
sample  should  be  obtained.  The  sample  should  be  shaken 
thoroughly  and  a  portion  of  it  poured  off  into  a  sterile 
bottle  for  a  bacteriological  analysis.  Care  should  be 
taken  not  to  wash  in  any  dirt  on  the  mouth  of  the  pint 
or  quart  bottle  during  the  process  of  pouring  the  bac- 
teriological sample.  It  is  advisable  in  most  cases,  unless 
the  bottle  is  provided  with  a  cap  that  fits  over  the  mouth, 
to  wipe  the  mouth  of  the  bottle  with  a  clean  piece  of  linen. 
If  the  surveyor  has  long,  sterile  tubes  which  can  be  em- 
ployed for  obtaining  the  bacteriological  samples,  these 
should  be  used  in  preference  to  anything  else.  After  the 
bacteriological   sample   is   collected,   the   surveyor  should 


146 


MILK-SUPPLY 


take  and  record  the  temperature  of  the  milk,  which  should 
then  be  capped  and  iced,  and  reserved  for  the  chemical 
examination. 

By  this  combined  series  of  inspections  and  examinations, 
a  clear  and  true  picture  of  the  milk-supply  will  be  obtained. 
From  such  a  study,  it  is  possible  to  make  justifiable  recom- 
mendations for  improvement. 


1  vi  ^  4|h| 

-  m|l 

miflm^^ 

''^^^-""•lii*--        '^^^■l  ^ 

'*  .^  m  f 

MmaBr^Mik 

Fig.  45.  Interior  of  a  milk  house  showing  the  sterihzer  for  the 
bottles,  the  milk  cooler,  and  the  bottle  filhng  machine. 

Recording  the  Chemical  and  Bacteriological  Results.  — 
The  following  table  will  prove  of  value  in  recording  the 
results  of  the  chemical  and  bacteriological  analyses.  In 
tabulating  the  results,  it  is  preferable  to  arrange  the  names 
of  the  producers  in  alphabetical  order 


CHEMICAL   AND   BACTERIOLOGICAL  ANALYSES        147 


TABLE  7 
CHEMICAL   AND   BACTERIOLOGICAL  ANALYSES  OF  MILKS 


Source. 


Temperature 
on  arrival. 

Degrees 
Fahrenheit. 


Specific 
gravity. 


Per  cent 
fats. 


Total  number 

of  bacteria  per 

c.c.  on  agar  at 

37° C. lor 

twenty-four 

hours. 

Dilution. 


Fermentation 

in  lactose 

broth  at  37°  C. 

for  twenty-four 

hours. 

Dilution. 


Fig.  46.  The  bottle  washing  apparatus  where  plenty  of  hot  water 
is  always  available  and  where  a  mechanically  revolving  brush  aids  in 
cleaning  the  bottles. 


148 


M1LK-8UPPLY 


The  following  tables  summarize  the  results  obtained 
from  the  chemical  and  bacteriological  analyses  and  are 
therefore  of  value.  It  is  inv  ortant,  of  course,  not  only  to 
record  the  data  for  each  table,  but  to  discuss  the  results 
obtained. 

TABLE  8 

CLASSIFICATION  OF  MILKS  ACCORDING  TO  TEMPERATURE 

ON   ARRIVAL   IN   THE   CITY 


Temperature  on  arrival. 

Private 
dealers. 

Distributing 
Dairy  A. 

Distributing 
Dairy  B. 

Distributing 
Dairy  C. 

Above      90°  F 

Between  80-90°  F 

Between  70-80°  F 

Between  60-70°  F 

Between  50-60°  F 

Between  40-50°  F 

Totals 

• 

Temperature  on  arrival. 

Per  cent. 

Above      90°  F 

Between  80-90°  F 

Between  70-80°  F 

Between  60-70°  F 

Between  50-60°  F 

Between  40-50°  F 

Total 

100.0 

MILKS  ACCORDING  TO  BACTERIAL  CONTENT   149 


JWBli 


Fig.  47.  Device  employed  at  the  model  cow  barn  at  Ardmore, 
Okla.,  for  removing  the  manure  from  the  barn.  As  soon  as  the  wagon 
is  filled  it  is  hauled  off  into  the  fields  and  emptied.  In  this  way  the 
fly  nuisance  is  almost  eliminated. 


TABLE  9 

CLASSIFICATION     OF    MILKS    ACCORDING    TO    BACTERIAL 

CONTENT 


Bacterial  content. 


Milks 
Milks 
Milks 
Milks 
Milks 
Milks 


containing 
containing 
containing 
containing 
containing 
containing 


over  1,000,000 
500,000-1,000,000 
200,000-  500,000 
100,000-  200,000 
50,000-  100,000 
less  than      50,000 


Bacteria  per  c.c. 
Bacteria  per  c.c. 
Bacteria  per  c.c. 
Bacteria  per  c.c. 
Bacteria  per  c.c. 
Bacteria  per  c.c. 


Total. 


Number  over     200.000  per  c.c. 
Number  under  200,000  per  c.c. 


150 


MILK-SUPPLY 


TABLE   10 

CLASSIFICATION    OF    MILKS    DELIVERED    TO    THE    CITY   BY 
VARIOUS    PRODUCERS,    ACCORDING    TO    BACTERIAL 

CONTENT 


Bacterial  content . 


Over         1,000.000  Bacteria  per  c.c. 

Between  500,000-1,000,000  Bacteria  per  c.c. 
Between  200,000-  500,000  Bacteria  per  c.c. 
Between  100,000-  200.000  Bacteria  per  c.c. 
Between  50,000-  100,000  Bacteria  per  c.c. 
Less  than     50.000  Bacteria  per  c.c. 

Totals 


Per  cent. 


Fig.  48.  An  excellent,  simple  and  inexpensive  milk  house  where 
the  best  care  is  taken  to  insure  a  safe,  clean  milk.  The  milk  house  and 
barn  were  exceptionally  clean  and  free  from  flies.  Note  the  orderlj' 
arrangement  of  things  outside  the  milk  house.  They  bespeak  the  care- 
ful habits  of  the  owner. 

It  may  be  desirable  to  use  other  bacterial  limits  than 
those  suggested  nhoxe,  as  a  means  of  classifying  the  samples. 


SPECIFIC  GRAVITY 


151 


The  bacterial  limits  employed  should  depend  in  a  large 
measure  on  the  results  obtained,  and  also  on  the  bacterial 
standards  which  the  health  surveyor  will  recommend  as  a 
result  of  studying  all  the  factors  involved.  The  important 
factors  which  should  be  considered  in  dete  mining  stand- 
ards are  the  distance  from  which  the  milk  comes,  the  age 
of  the  milk,  and  the  season  of  the  year.  It  is  obviously 
easier  to  obtain  a  low  bacterial  count  during  the  cold 
months  than  during  the  warm  months.  This  factor 
should  therefore  be  considered  in  determining  standards. 
The  standards  for  pasteurized  milk  must  necessarily  be 
different  than  those  for  raw  milk.  If  the  milk  is  graded, 
it  is  obvious  that  there  will  be  a  standard  for  each  grade. 
Similarly,  the  standards  for  certified  milk  must  be  different 
from  those  employed  for  ordinary  raw  milk. 

Other  tables  that  are  of  value  in  recording  the  results  of 
the  analyses  are  given  below. 

TABLE   11 

CLASSIFICATION  OF  MILKS  ACCORDING  TO  FERMENTATION 
IN   LACTOSE   BROTH   IN    1  100    OF   A   C.C. 


Number  of  Samples  Examined 

Number  Showing  Fermentation  in  1/100  c.c 

Number  not  Showing  Fermentation  in  1/100  c.c. 


Number, 


Per  cent. 


TABLE   12 

CLASSIFICATION    OF   MILKS   ACCORDING   TO    SPECIFIC 

GRAVITY 


Specific  gravity. 

Number. 

Per  cent. 

Above  1  029           

Below  1  029                        

Totals              

152 


MILK-SUPPLY 


TABLE   13 

CLASSIFICATION    OF   MILKS   ACCORDING   TO   FAT- 
CONTENT 


Fat-content. 


Above  3 . 5  per  cent 

Below  3.5  per  cent 

Totals 


Number. 


Per  cent. 


In  some  cities,  the  minimum  requirement  for  fat-content 
in  milk  is  less  than  3.5  per  cent.  Where  this  is  the  case, 
the  table  should  be  rearranged  so  as  to  give  the  number 
of  samples  examined  which  had  a  fat-content  between  the 
authorized  local  minimum  requirement  and  3.5  per  cent, 
and  also  the  number  of  samples  having  less  than  the 
authorized  local  minimum  fat  requirement. 

The  results  of  the  inspections  of  the  distributing  dairies 
can  be  tabulated  as  follows. 


TABLE  14 

SHOWING    THE    QUANTITIES   OF    MILK  HANDLED   BY  THE 

LARGE   DAIRIES   AND    ICE-CREAM    COMPANIES,   AND 

THE    METHODS   EMPLOYED 


Distrib- 
utor. 

Number  of 
Producers. 

Amount 

of  milk 

handled, 

in  gallons 

per  day. 

Greatest 
distance 

from  which 
milk 

is  delivered. 

Pasteur- 
ized. 

Bottles 

effect  ively 

washed  and 

sterilized. 

Milk-room 

effectively 

screened. 

A 
B 
C 
D 
E 

POINTS  THAT  SHOULD   BE  STRESSED 


153 


Points  that  should  be  Stressed  in  the  Report  on  the  Milk- 
Supply.  —  In  writing  the  report  on  the  condition  of  the 
local  milk-supply,  several  factors  should  be  given  particu- 
lar emphasis,  especially  if  local  practice  seems  to  ignore 
them.  In  order  to  insure  a  satisfactory  milk-supply,  it  is 
important  that  the  dairies  be  inspected  frequently  by  a 
competent,  well-trained  and  tactful  milk  inspector.  The 
purpose  of  these  inspections  should  not  be  merely  to  detect 
evil  conditions  and  evil  practices,  but  should,  in  a  large 
measure,  be  educational,  as  many  of  the  undesirable  con- 
ditions   affecting    milk-production    can    be    remedied    by 


Fig  49.  A  cheap  barn  having  a  concrete  floor,  which  is  kept  un- 
usually clean.  Milk  having  a  low  bacterial  count  is  produced  under 
these  conditions.  Expensive  barns  are  not  essential  to  the  production 
of  clean  milk 

educating  the  farmer.  The  desired  result  can  usually 
be  attained  not  by  the  purchases  of  costly  apparatus,  but 
by  the  use  of  simple  things  and  simple  principles  which  are 
available  even  to  the  very  poor.  What  the  farmer  fre- 
quently lacks  is  proper  knowledge  of  how  to  do  the  right 
thing.     Often,  too,  he  does  not  appreciate  the  significance 


154 


MILK-SUPPLY 


of  the  things  he  is  asked  to  do.  If  he  can  be  shown  that 
the  desirable  practices  can  be  introduced  with  but  httle, 
if  an}',  additional  cost,  and  can  be  made  to  understand 
what  a  clean  and  safe  milk-suppl}'  means  to  babies  and 
children,  it  will  usuall}'  nob  be  difficult  to  bring  about  an 
improvement  in  the  supply. 


Fig.  50.  A  properly  equipped,  clean  and  inexpensive  milk  house 
containing  excellent  facilities  for  washing  and  sterilizing  bottles  and 
for  cooling  milk.  In  the  foreground  is  a  sample  of  a  small-mouth 
milk  pail,  which  is  essential  in  producing  clean  milk. 

Besides  recommending  frequent  inspections  at  the 
source  of  production,  it  is  important  to  stress  the  frequent 
analysis  of  the  milk.  Only  by  a  combination  of  inspections 
and  laboratory  analyses  can  a  complete  knowledge  of  the 
milk-supply  be  gained.  It  is  possible  to  determine  from 
the  laboratory  tests  whether  the  milk  has  been  watered  or 
skimmed,  whether  it  has  been  kept  at  a  high  temperatiu'e, 
whether  the  bacterial  content  is  too  high,  and  whether 
the  milk  is  polluted  with  organisms  of  fecal  origin.  The 
value  of  the  results  is  greatly  enhanced  if  they  are  pub- 
lished periodically  in  the  local  newspapers. 


OUTLINE   OF   CHAPTER  ON   MILK-SUPPLY  155 

Another  practice  which  should  be  recommended  is  the 
pasteurization  of  the  entire  milk -supply  by  the  holding 
method,  under  proper  and  intelligent  supervision  and 
control.  Only  by  this  means  can  the  safety  of  the  milk- 
supply  be  insured.  Other  points  which  should  receive 
attention  are  the  periodic  testing  of  the  cows  for  tuber- 
culosis, the  grading  of  milk,  and  the  medical  examination 
of  all  persons  engaged  in  producing  or  handling  the  milk. 

The  following  outline  will  be  of  service  in  writing  this 
part  of  the  report. 

OUTLINE    OF    CHAPTER   ON    MILK-SUPPLY 

1.  Importance  and  value  of  milk  as  a  food.  Relation  between  the 
milk-supply  and  the  public  health.  Pasteurization  by  the  holding 
method,  the  only  real  safeguard  of  a  municipal  milk-supply. 

2.  Results  of  interview  with  the  milk  inspector. 

3.  Results  of  dairy  inspections  and  discussion. 

4.  Results  of  inspections  of  the  distributing  dairies,  and  discussion. 

5.  Results  of  laboratory  analyses  and  discussion. 

6.  Conclusions. 

7.  Summary. 

8.  Recommendations. 


CHAPTER   IX 

INSPECTION    OF    RESTAURANTS,    LUNCH    ROOMS 

AND    FOOD    STORES 

Sanitation  of  Public  Eating-Places,  Necessary  to  Protect 
Public  Health.  —  With  the  growth  of  cities,  and  the  re- 
moval of  the  seat  of  industry  from  the  home  to  the  factory, 
office  and  workshop,  and  with  the  development  of  increased 
and  better  facilities  for  travel,  there  has  arisen  a  need  for 
public  eating-places.  Almost  everybody  who  is  employed 
away  from  home  during  the  day,  and  most  of  those  who 
are  traveling  or  who  are  living  away  from  home,  find  it 
necessary  every  day  to  have  some  of  their  meals  at  public 
lunch  rooms  and  restaurants. 

In  some  of  the  large  metropolitan  centers  like  New 
York,  Chicago,  Philadelphia  and  Boston,  there  are  thou- 
sands of  such  establishments,  where  the  food  is  handled 
by  all  sorts  of  people  and  under  all  sorts  of  conditions. 
Many  of  the  people  who  eat  in  these  places  may  be  tuber- 
culous; some  may  be  diphtheria  carriers  or  may  be  affected 
with  venereal  disease,  or  some  other  infectious  malady. 
These  people  leave  scraps  or  traces  of  food  on  their  plates, 
and  the  dishes  and  other  utensils  which  they  use  are  likely 
to  become  soiled  w^ith  the  secretions  from  the  mouth,  and 
thus  infected  with  the  germs  that  are  present.  It  is, 
therefore,  exceedingh^  important  that  the  dishes,  glasses 
and  cutlery  which  arc  used  during  meals  should  be 
thoroughly  cleansed  and  sterilized  })efore  being  used  again. 

Danger  from  Food-Handlers  who  are  Diseased  or  are 
Carriers  of  Disease.  —  Students  of  sanitary  science  are 
familiar  with  the  history  of  Typhoid  Mary,   who  was  a 

156 


SUPERVISING   RESTAURANTS  157 

typhoid  carrier,  and,  while  serving  as  a  cook,  was  respon- 
sible for  many  cases  of  typhoid  fever.  Such  a  case  only 
demonstrates  the  necessity  for  preventing  carriers  of  dis- 
ease from  working  as  cooks  or  food-handlers.  Such  indi- 
viduals should  seek  employment  in  other  fields,  where  they 
will  not  be  a  menace  to  the  public  health. 

In  order  to  determine  whether  food-handlers  are  dis- 
eased or  are  carriers  of  disease,  it  is  necessary  for  ever}^ 
person  so  employed  to  undergo  thorough,  periodic,  medical 
examinations  in  which  laboratory  tests  are  made  to  deter- 
mine the  condition  of  the  individual.  Without  these  tests, 
it  is  impossible  to  determine  whether  a  person  is  a  carrier, 
or  to  establish  definitely  that  he  is  diseased.  Food- 
handlers  should  be  examined  at  least  once  a  year,  and 
oftener  if  possible,  and  only  those  who  are  free  from  dis- 
ease should  be  allowed  to  serve  in  this  capacity. 

The  **  Rush  Period  "  in  Restaurants  is  the  Time  when 
Sanitary  Precautions  are  Most  Important.  —  The  time 
when  food  is  apt  to  be  insufficiently  cooked,  and  both  food 
and  dishes  are  likely  to  be  handled  in  an  unsanitary  man- 
ner is  just  the  time  when  sanitary  precautions  are  most 
necessary.  The  hours  between  11  a.m.  and  2  p.m.  are  un- 
doubtedly the  busiest  part  of  the  day,  in  any  lunch  room 
or  restaurant.  During  these  hours  people  are  constantly 
coming  and  going,  and  sometimes  have  to  wait  until  a 
seat  at  a  table  is  available.  The  waiters  are  hurried  and 
overworked;  the  cook  must  furnish  the  food  as  quickly  as 
possible;  and  the  dishwasher  must  prepare  a  fresh  supply 
of  dishes,  glasses  and  eating  utensils  just  as  quickly  as  he 
possibly  can.  It  is  at  such  times  that  the  precautions 
necessary  to  prevent  the  spread  of  disease  are  practised 
the  least;    and  it  is  then,  too,  that  the  danger  is  greatest. 

Work  of  the  Health  Department  in  Supervising  Restau- 
rants should  be  Carefully  Studied.  —  Because  of  the 
increase  in  the  number  of  public  eating-places,  and  of  the 


158  INSPECTION  OF  RESTAURANTS,  ETC. 

dangers  to  the  public  health  which  are  inherent  in  the 
preparation  and  handling  of  food  and  eating-utensils,  it 
has  become  necessary  for  health  departments  to  supervise 
public  eating-places,  and  compel  them  to  observe,  as  far 
as  possible,  those  regulations  which  arc  designed  to  pre- 
vent the  spread  of  disease.  If  the  lunch  rooms  and  restau- 
rants are  frequently  inspected  by  local  health  officials,  the 
surveyor  should  become  acquainted  with  the  conditions 
that  have  been  brought  to  light  as  a  result  of  these  inspec- 
tions. He  should  ascertain  how  often  the  inspections  are 
made,  and  whether  a  score-card  is  used  to  determine  the 
degree  to  which  each  place  complies  with  the  regulations 
of  the  sanitary  code.  If  a  score-card  is  employed,  a  copy 
of  the  card  should  be  obtained  for  further  study,  and  the 
previous  ratings  should  also  be  obtained  for  possible  use 
in  the  final  report. 

The  surveyor  should  also  ascertain  what  is  accomplished 
after  the  inspections  are  made  and  the  defects  recorded. 
Is  any  follow-up  work  done  to  remedy  defects?  If  so, 
what  has  been  accomplished?  Are  food-handlers  required 
to  undergo  a  thorough  medical  examination,  which  includes 
laboratory  tests?  What  laboratory  tests  are  made?  Are 
the  examinations  periodic?  If  so,  what  is  the  period? 
Are  the  examinations  free  ?  By  whom  are  they  performed  ? 
If  a  charge  is  made,  what  is  the  charge? 

Are  cards  issued  to  those  who  successfully  pass  the 
examination?  Are  the  eating-places  licensed?  Are  they 
required  to  show  evidence  that  they  have  successfully 
passed  the  last  inspection?  Do  the  inspectors  attempt  to 
educate  the  proprietors  of  the  eating-places  in  the  proper 
methods  necessary  to  protect  the  public  health? 

Surveyor  should  Personally  Inspect  Restaurants.  —  In 
order  to  determine  the  conditions  under  which  food  is 
prepared  and  served,  it  will  be  necessary  for  the  surveyor 
or  his  assistants  to  visit  the   public  eating-places  and  to 


FORM  CARDS  INDICATE   IMPORTANT  FACTORS       159 

make  personal  inspections.  If  possible,  all  the  eating- 
places  in  the  city  should  be  inspected.  Where  time  does 
not  permit  such  a  thorough  survey,  the  restaurants  and 
lunch  rooms  which  are  most  often  used  by  the  people 
should  be  inspected.  These  places  will  be  found  in  the 
business  section  of  the  city. 

In  order  to  have  all  the  inspections  performed  in  a  uni- 
form manner,  it  is  desirable  to  use  a  special  form-card. 
Two  specimens  are  reproduced  in  this  chapter.  One  is  in 
reality  a  report-card,  and  the  other  a  score-card.  The 
former  is  practically  the  same  as  the  card  used  by  the 
New  York  City  Health  Department  and  seems  superior 
in  many  ways  to  the  score-card.  It  emphasizes  the  factors 
which  are  of  primary  significance  from  the  public  health 
standpoint,  and  does  not  require  the  inspector  to  estimate 
to  a  fraction  of  a  point  the  degree  to  which  a  certain  con- 
dition or  practice  exists.  It  does  away  with  the  personal 
element  which  must  always  be  considered  in  filling  out  a 
score-card,  and  '  simply  requires  the  inspector  to  report 
either  affirmatively  or  negatively  on  the  existence  of  a 
certain  condition.  For  those  who  prefer  a  score-card, 
however,  the  second  form  will  be  of  value. 

Form  Cards  Indicate  most  Important  Factors.  —  It  is 
not  necessary  here  to  suggest  the  questions  necessary  to 
obtain  the  desired  information,  as  the  forms  which  are 
recommended  serve  that  purpose.  It  is  not  necessary 
either,  to  explain  any  of  the  items  which  are  recorded  in 
the  forms,  as  the  reason  for  each  must  be  obvious  to  any- 
body undertaking  a  public  health  survey. 

In  order  to  obtain  the  temperature  of  the  refrigerators, 
it  will  of  course  be  necessary  for  the  surveyor  to  have  a 
thermometer  with  him  at  all  times.  The  lactometer  read- 
ings on  the  milk  which  is  sold  can  be  made  on  a  represen- 
tative sample  obtained  from  the  can,  if  the  milk  is  kept 
in  bulk,  or  else  on  a  bottle  of  milk  which  has  been  selected 


160 


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^ 

H 

164  INSPECTION  OF  RESTAURANTS,  ETC. 

at  random  from  all  those  present,  and  thoroughly  shaken 
before  the  test  is  made. 

It  may  be  desirable  to  note  more  specifically  the  methods 
employed  for  washing  and  sterilizing  the  dishes,  so  as  to 
be  able  to  discuss  this  procedure  fully  in  the  report.  Any 
malpractice  which  seems  to  be  particularly  prevalent 
should  be  carefully  noted  and  fully  discussed. 

If  report-cards  like  that  shown  above  have  been  used 
in  making  the  inspections,  an  unused  card  may  be  em- 
ployed for  tabulating  the  results.  The  number  of  restau- 
rants found  satisfactory  and  the  number  found  unsatis- 
factory, in  each  particular,  can  be  recorded  on  this  card. 
The  reader  can  then  see  at  a  glance  the  conditions  that 
prevail  throughout  the  city.  Where  the  score-card  is 
used,  tables  similar  to  those  shown  in  the  chapter  on  milk- 
supply  may  be  employed  in  the  final  report  on  conditions 
prevaihng  in  the  city.  The  surveyor  may  see  fit  to  pub- 
lish the  separate  score-card  ratings  for  each  restaurant; 
or  he  may  prefer  to  publish  only  the  summary  for  all  the 
stores  inspected.  His  decision  on  this  point  should  be 
based  on  a  consideration  of  local  conditions.  The  mini- 
mum score  necessary  for  a  passing  grade  is  assumed  to  be 
65  per  cent. 

Inspection  of  Food-Stores 

Food-Stores  should  also  be  Inspected  and   Scored.  — 

The  inspection  of  food-stores  is  not  as  important  as  the 
inspection  of  restaurants  and  lunch  rooms.  Most  of  the 
foods  that  are  bought  in  the  stores  for  home  consumption 
are  washed  and  cooked  before  they  are  eaten;  and  foods 
which  are  eaten  raw,  such  as  fruit  and  certain  vegetables, 
are  frequently  washed  and  wiped.  Nevertheless,  if  only 
for  aesthetic  reasons,  it  is  desirable  that  the  premises 
where  foods  are  sold  should  be  kept  clean.  It  is  also  desir- 
able to  protect  the  foods  in  the  store  from  unnecessary 


INSPECTION  OF  FOOD-STORES  165 

filth,  such  as  that  resulting  from  careless  sweeping  or  from 
the  presence  of  flies.  For  these  reasons  it  is  customary  to 
require  that  most  foods  be  covered  and  thus  protected 
against  flies,  dust  and  dirt. 

It  is  also  important  that  employees  should  be  provided 
with  adequate  and  satisfactory  toilet  and  washing  facili- 
ties, and  that,  where  readily  decomposable  food  is  kept 
for  sale,  such  food  should  be  thoroughly  iced.  The  garbage- 
pail  should  be  made  of  impervious  material  and  should  be 
kept  tightly  covered  at  all  times,  in  order  not  to  attract 
flies.  Where  ice-cream  and  soft  drinks  are  sold,  particular 
attention  should  be  given  to  the  method  of  cleaning  and 
sterilizing  the  utensils. 

The  surveyor  or  his  assistants  should  inspect  all  the 
food-stores,  or  as  many  of  the  important  ones  as  time  will 
permit.  The  condition  of  these  stores  may  be  indicated 
by  using  the  score-card  given  below.  In  reporting  the 
results  of  this  survey,  the  surveyor  may  record  the  score 
of  each  individual  store,  or  he  may  devise  a  table,  similar 
to  that  suggested  in  the  chapter  on  milk-supply,  wherein 
all  the  stores  will  be  divided  into  two  groups  according 
to  their  score-card  ratings.  Those  receiving  at  least  65 
per  cent  will  be  considered  satisfactory,  and  those  receiv- 
ing less,  unsatisfactory. 


166 


INSPECTION  OF  RESTAURANTS,  ETC. 


SCORE-CARD   FOR   FOOD-STORES 


Name Kind 


Address Date. 


SCORE. 


Perfect. 


Construction  of  Store 

1.   Above  the  sidewalk  level. 


2.  Free  from  contaminating  surroundings 

3.  Store  light  and  well  ventilated 

4.  Unconnected  by  door  or  hall  with  living  room 0.5 

5.  Market  not  directly  connected  with  toilet 

6.  Plumbing  in  good  condition 

7.  Floor  of  store  —  smooth  and  tight 

8.  Sidewalls  and  ceiling  —  smooth  and  tight 0.5 

9.  Doors  and  other  openings  well  screened 

10.  Store  provided  with  basin  and  running  water 

11.  Cellar  —  clean,  well  ventilated,  cement  floor,  no  odor 0.5 


10 


Cleanliness  of  Store 

1.  Floor  —  especially  near  foods 3 

2.  Walls  and  ceiling 1 

3.  Windows 1 

4.  Display  cases,  windows  and  shelves 2 

5.  Blocks  and  counters 2 

€..    Utensils  and  instruments 3 

7.  Ice-box 3 

8.  Disposal  of  waste  —  covered  garbage-pails  (metal) 4 

9.  Sink,  hot  running  water,  individual  towels 6 

25 


Exposure  of  Food  Supplies 

1.  Nothing  displayed  outside  of  store  except  under  glass  covers 4 

2.  Store  free  from  flies 4 

3.  All  unwrapped  foods  and  fruits  protected  from  flies  and  dust 4 

4.  Protection  in  delivery;  wrapped;  clean  wagon 4 

5.  Show  windows  closed 5 

6.  Foodstuffs  at  least  24  inches  above  floor 4 

25 


Allowed. 


SCORE-CARD   FOR  FOOD-STORES 


167 


SCORE. 


Employees 


Perfect. 


1. 
2. 
3. 
4. 


Wear  clean  uniforms 4 

Clean  —  wash  hands  after  visiting  toilet 8 

Employees  examined  —  free  from  disease 5 

Do  employees  moisten  fingers  with  saliva  for  any  purpose 8 


25 


Stores  Where  Milk  Products  are  Sold 

1.  Milk  and  cream  kept  in  ice  tubs  and  covered 4 

2.  Dippers  are  seamless,  sanitary,  tight,  clean 2 

3.  Separate  dippers  for  each  can 2 

4.  Butter  kept  in  clean  ice-box 4 

5.  Cheese  cases  clean 3 


15 


Stores  Wuere  Meat  or  Fish  is  Sold 

1.  Counters,  beaches,  refrigerators  of  hardwood,  watertight,  cleanable. .  3 

2.  Refrigerators,  temp.  40"  F.  or  below 3 

3.  Ice  in  separate  compartment  from  meats 2 

4.  All  meats  inspected  and  fresh 4 

5.  Is  all  fish  iced  and  stored  without  nuisance 3 


.15 


Stores  Where  Ice-Cre.\m  and  Candy  are  Sold 

1.  Soda-fountains,  refrigerators  —  cleanable 3 

2.  All  utensils  washed  in  running,  hot  wate." 3 

3.  Individual  containers  used 1 

4.  All  milk  and  cream  of  good  quality 3 

5.  Ice-cream  made  under  sanitary  conditions 3 

6.  All  unwrapped  candies  protected  from  dust  and  flies 2 


15 


Bakeries 

1.  Materials  used  of  good  quality 5 

2.  Sanitary  mechanical  appliances  used  in  baking 3 

3.  Breadstuffs  provided  with  dustproof  wrapper 3 

4.  Bakery  floor,  hardwood,  clean 2 

5.  Bakers  clean,  special  uniforms 2 


15 


Summary 

Construction  of  Store 10 

Cleanliness  of  Store 2o 

Exposure  of  Food  Supplies 25 

Employees 25 

Miscellaneous 1^ 

Total  Score ^^ 


Allowed. 


168 


INSPECTION  OF  RESTAURANTS,  ETC. 


Another  means  of  classification  is  given  in  the  following 
table. 

TABLE   lo 

CLASSIFICATION    OF   FOOD-STORES   ACCORDING   TO 

SCORE-CARD    RATING 


Rating. 


Between  90-100 

Between  So-  90 

Between  80-  85 

Between  75-  80 

Between  70-  75 

Between  65-  70 

Between  60-  65 

Between  50-  60 

Between  40-  50 

Between  30-  40 

Total  number  of  food-stores  inspected. 


Number. 


Another  table  which  will  also  aid  in  presenting  the  data 
obtained  as  a  result  of  the  inspections  follows. 

TABLE   16 
KIND    AND    NUMBER    OF   FOOD-STORES   INSPECTED 


Kind  of  stoie. 

Number. 

Bakeries            

Confect  ionerv                  

Grocery                   

Grocerv  and  meats                         

total 

Number. 

Per  Cent. 

Stores  scorinn  above  65  ner  cent   

Stores  scoring  below  65  per  cent 

Total 

1 

OUTLINE   OF   CHAPTER  169 

OUTLINE  OF  CHAPTER  ON  INSPECTION   OF  RESTAURANTS 

AND   FOOD-STORES 

1.  Importance  of  supervising  public  eating-places  and  food-stores. 
Control  over  food-handlers  is  also  of  prime  importance. 

2.  Study  of  previous  imspections  and  work  aiming  to  better  the 
conditions  in  the  pubhc  eating-places  and  food-stores. 

3.  Personal  inspections  of  public  eating-places  and  food-stores,  and 
the  use  of  report-cards  or  score-cards  for  the  work. 

4.  Summary. 

5.  Recommendations. 


CHAPTER   X 

HOUSING 

The  Housing  Problem  is  a  Serious  One  in  Many  Com- 
munities. —  Much  has  been  said  and  written  on  the  sub- 
ject of  housing.  Many  have  maintained  that  housing  has 
a  fundamental  and  exceedingly  important  relation  to  good 


i 


Fig.  51.  A  street  in  a  tent  colony  where  overcrowding  was  very 
prevalent  and  where  water  and  sewer  facihties  were  absent.  Rents 
however  were  abnormally  high. 

health,  and  that  it  is  the  cause  of  tuberculosis  and  other 
diseases.  There  is  no  doubt  that  the  housing  problem  is 
of  prime  importance,  for  everybody  must  have  shelter  of 
some  kind.  During  the  war,  housing  facilities  became  very 
limited,  and  in  some  places  where  war  materials  were  being 
manufactured,  homes  of  any  kind  have  been  at  a  premium, 

170 


OVERCROWDING  SERIOUS 


171 


and  have  been  difficult  to  get,  even  at  exorbitant  prices. 
Because  of  the  increase  in  the  cost  of  materials,  the  high 
wages  demanded  by  labor,  and  the  diversion  of  labor  from 
the  construction  of  homes  to  other  fields  of  activity,  the 
shortage  in  houses  has  become  more  acute  than  ever.  Rents 
have  increased  and  people  are  required  to  pay  inflated 
prices  for  decent  shelter,  or  to  seek  poorer  quarters  else- 
where. 


Fig.  52.     A  street  of  very  poor  shacks  in  a  large  city,  where  water 
and  toilet  facilities  do  not  exist,  and  where  overcrowding  is  widespread. 


Overcrowding  is  Probably  the  Most  Serious  Public 
Health  Aspect  of  Housing.  —  It  is  exceedingly  doubtful 
whether  a  poorly  built  house  is,  in  itself,  injurious  to  health. 
It  is  also  very  doul^tful  whether  the  house  itself  is  ever  the 
cause  of  tuberculosis  or  any  other  communicable  disease. 
There  are,  however,  certain  distinct  evils  associated  with 
housing,  which  doubtless  tend  to  undermine  the  resistance 
of  the  people,  which  have  an  undesirable  effect  upon  their 
mental  attitude,  and  which  favor  the  spread  of  disease. 
Homes   that    are    overcrowded    are   likely   to    spread   the 


172 


HOUSING 


germs  of  disease,  not  because  the  home  is  badly  constructed 
or  in  poor  repair,  or  because  overcrowding,  in  itself,  causes 
disease,  but  because  overcrowding  brings  about  frequent 
and  intimate  contact  between  persons,  with  the  resulting 
transfer  of  secretions  and  excretions  from  one  to  another. 
Overcrowding  also  results  in  the  production  of  noise  and 
of  other  irritating  circumstances,  which  prevent  calm, 
peaceful  sleep,  and  thus  undermine  the  resistance  of  the 
mental  and  physical  mechanisms.     It  also  prevents  privacy 


Fig.  53.  Interior  view  of  a  room,  where  three  families  reside.  The 
room  is  divided  into  three  sections  by  transparent  curtains.  Very  little 
privac}'^  is  afforded  in  this  way. 

and  breeds  undesirable  familiarity,  thus  fostering  social 
vices  or  evils  and  constantly  stimulating  the  sexual  emotions 
and  cravings.  It  does  not  favor  clean  habits,  and  is  unde- 
sirable for  that  reason,  as  well  as  for  those  previously  stated. 
Overcrowding  is  doubtless  one  of  the  most  serious  evils 
associated  with  housing,  and  should  be  combated  most 
earnestly  from  the  moral  and  social  standpoints,  the  stand- 
point of  decency,  and  that  of  public  health. 


OTHER  SERIOUS  HOUSING  EVILS 


173 


Other  Serious  Housing  Evils:  the  Lack  of  a  Public 
Water-Supply  and  Sewerage  System.  —  There  are  other 
housing  evils  which  are  also  important,  inasmuch  as  they 
indirectly  affect  the  health  and  decency  of  the  people. 
Such  evils,  for  example,  as  the  absence  of  an  adequate  and 
safe  water-supply  and  the  lack  of  modern  sewerage  facili- 
ties  are    particulaily   important   from    the    public   health 


,^P 


Fig.  54.  A  shaek  having  only  one  room  where  two  famiUes  resided. 
Water  and  sewer  facilities  were  absent 

standpoint.  Not  only  does  the  lack  of  a  safe  municipal 
supply  usually  mean  that  the  private  supply  is  more  likely 
to  be  polluted,  but  it  also  means  that  the  people  must 
experience  great  hardship  in  getting  enough  water.  If  the 
water  used  in  the  home  has  to  be  carried  from  a  well, 
cistern  or  spring,  or  even  from  a  pipe-line  which  does  not 
enter  the  house,  water  will  be  used  sparingly,  and,  as  a 
result,  certain  hygienic  practices  will  be  neglected. 

The  lack  of  modern  sewerage  facilities  usually  means 
that  the  open  privy  is  employed.  That  the  latter  is  a 
nuisance  as  well  as  a  menace  to  the  public  health  is  doubt- 


174 


HOUSING 


less  true.  It  may  serve  as  a  source  of  pollution  for  nearby 
wells;  or,  through  the  agency  of  flies,  which  pass  from 
the  privy  to  the  kitchen  and  to  the  dining-room  table,  it 
may  endanger  the  health  of  the  people.  The  existence  of 
open  privies  usually  also  means  a  higher  infant  mortality 
rate,  due  primarily  to  the  flies  which  carry  infectious 
material  from  the  privy.  The  lack  of  modern  sewerage 
facilities  also  interferes  with  the  regular  normal  process  of 
excretion.  Where  toilet  facilities  are  not  convenient  and 
readily  available,  people  will  often  suppress  an  elimination 
rather  than  answer  nature's  call  under  unpleasant  and 
sometimes  adverse  circumstances. 


Fig.  55.  A  few  "shacks,"  used  as  homes  by  Mexicans,  where  some 
incredible  housing  evils  prevail.  The  pail  in  the  foreground  is  filled 
with  garbage  and  was  swarming  with  flies.  Note  also  the  rubbish  in 
the  yard. 


Housing  Evils  are  often  the  Fault  of  the  People  Them- 
selves. —  Other  factors  associated  with  housing  also  affect 
the  health  of  the  people.  The  home  must  be  heated  ade- 
quately and  satisfactorily,  and  it  should  also  be  properly 
ventilated.     Although    much    can    be    done    to    improve 


EVILS   FAULT  OF  PEOPLE  THEMSELVES 


175 


housing  conditions  by  providing  a  sufficient  number  of 
homes  which  are  well  built,  which  have  modern,  sanitary 
plumbing,  and  which  are  also  heated  and  ventilated  satis- 
factorily, the  solution  of  the  problem  depends  in  a  large 
measure  on  the  occupants  of  the  houses  themselves.  Some 
of  the  worst  housing  conditions  are  frequently  found  in 
thinly  settled  districts,  w^here  the  home  has  plenty  of  fresh 
air  and  sunlight,  but  where  the  occupants  do  not  know 
how  to  derive  the   greatest  benefit  from  their  favorable 


Fig.  56.     An  overcrowded,  hot,  fly-ridden  home  and  some  of  the 
occupants.     IModern  sanitary  conveniences  were  absent. 

situation.  Ignorant  people  who  have  been  supplied  with 
modern  homes  have  often  failed  to  utilize  the  facilities 
which  were  placed  at  their  disposal.  The  bath-tub  some- 
times becomes  a  coal-bin,  and  the  home  is  httered  with 
refuse,  dirt  and  rags.  Every  public  health  worker,  as  well 
as  every  social  reformer  and  statesman,  should  realize  that 
human  beings  are  biologically  different,  and  that  it  is 
impossible  to  bring  everybody  up  to  the  same  level  of 


176 


HOUSING 


decency,  culture,  refinement,  taste  and  accomplishment. 
We  can  only  hope  to  make  the  conditions  for  all  as  good 
as  possible,  and  to  help  others  to  reach  the  maximum  level 
of  their  powers  of  attainment.  Beyond  that  point,  human 
endeavor  meets  an  immovable  stone  wall. 


Fig.  57.  Some  juvenile  occupants  before  the  entrance  of  a  large 
tenement  and  lodging  house,  where  very  serious  housing  evils  exist. 
Overcrowding  and  lack  of  water  and  sewerage  facilities  are  outstanding 
evils. 


Collecting  the  Data  on  Housing.  —  In  the  chapter  deal- 
ing with  the  organization  for  the  survey,  a  complete  state- 
ment was  made  regarding  the  organization  and  conduct 
of  the  housing  survey.  The  form-card  which  is  recom- 
mended is  shown  below. 


HOUSE  INSPECTION  CARD 


177 


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178 


HOUSING 


The  surveyor  using  this  form  may  be  required  to  change 
certain  items,  to  add  others,  and  to  omit  some  that  are 
given,  according  to  local  conditions.  On  the  whole,  it  is 
believed  that  the  form-card  suggested  will  bring  out  the 
important  information  required  for  a  public  health  survey. 

There  is  little  else  to  add  to  the  description  of  the  organi- 
zation and  operation  of  the  housing  survey.  The  surveyor 
or  his  assistants  should  supplement  the  census  and  inspec- 
tions by  personal  inspections  and  studies  of  housing  con- 
ditions in  the  poorer  sections  of  the  city  and  in  the  room- 
ing-houses. After  the  survey  is  over,  the  data  which  have 
been  collected  should  be  tabulated  and  shown  graphically. 
Numerous  photographs  should  accompany  the  report  on 
housing. 


Fig-.  58.     A  street  of  moderately  expensive  houses  where  the  sani- 
tary conditions  are  excellent. 

Tabulating  the  Results  of  the  Housing  Survey.  —  The 
following  tables  may  be  used  to  summarize  and  present 
the  lesults  of  the  housing  survey. 


HEIGHT  OF   DWELLINGS 


179 


TABLE   17 

SHOWING  THE  HEIGHT  OF  DWELLINGS  AND  THE  NUMBER 
OF   FAMILIES   PER   HOUSE   BY  WARDS 


Stories. 

Number  of  families  per  house. 

Ward. 

Total. 

1  2  3   t. 

No 

report. 

12  3  4  5  0  7  S-11  12-16. 

No 

report . 

1 

2 

3 

4 

Total... 

1 
1 

Fig.  59.     Typical  bungalow.s  in  Oklahoma  City.     These  make  very 
satisfactory  homes  in  the  Southwest. 


180 


HOUSING 


TABLE   18 

SHOWING  THE  KIND  OF  DWELLING,  THE  MATERIAL  USED 
IN  CONSTRUCTION  AND  THE  CONDITION  — BY  WARDS 


o 

Kind  of  dwelline;. 

Structure. 

Condition. 

Ward. 

g-g 

•So; 

S  o 

O  3 

1 

o 

1 

■4-' 

o 
a. 

£ 
o 

;5 

-3 
O 

o 
O 

U 

fe 

I-' 

o 

a 

£ 
o 

1 

2 

3 

4 



Total... 

Fig.  60.     A  typical  tent  home  in  the  tent  colony  at  West  Tulsa, 
Okla.,  where  the  housing  conditions  are  very  unsatisfactory. 


NUMBER  OF  PERSONS  PER  FAMILY 


181 


TABLE   19 

SHOWING    THE   NUMBER    OF    PERSONS    PER   FAMILY  —  BY 

WARDS 


Number  of  persons 
per  family. 

Total. 

Ward. 

1 

2 

3 

4 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15  and  over.  .  .  . 

Total 

Fig.  61.     A  street  of  well  kept  and  splendid  homes. 


182 


HOUSING 


TABLE  20 

SHOWING  THE  NUMBER  OF  ROOMS  PER  HOUSE  — BY 

WARDS 


Number  of  rooms. 


1 

2 

3 

4 

5 

6 

/ 

8 

9 

10 

11 

12 

13 

14 

15  and  over 
No  report .  , 

Total 


Total. 


Ward. 


2 


Fkj.  62.  A  street  of  expensive  homes  in  a  small  city,  where  the 
streets  have  not  yet  been  paved.  This  is  quite  apt  to  be  the  case, 
where  cities  develop  rapidly. 


RELATIONSHIP  OF  NUMBER  PER  FAMILY        183 


TABLE  21 

SHOWING  THE  RELATIONSHIP  OF  THE  NUMBER  PER  FAM- 
ILY  AND    THE   NUMBER   OF   ROOMS   OCCUPIED   IN 

WARD    (1,  2,  3,  4) 


Number 
in  family. 

Number  of  rooms. 
1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18,  etc. 

Total. 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

• 

TotaL.. 

'-#  mim^:,U^. 


•^■■% 


f^-i 


Fig.  63.     A  part  of  "Katy  Alley,"  known  for  its  poor  housing  con- 
ditions and  other  social  ills. 


184 


HOUSING 


TABLE   22 

SHOWING   THE   NUMBER   OF   BEDROOMS   IN   EACH   HOME 

BY   WARDS 


Number  of  bed- 

Total. 

Ward. 

rooms  per  house. 

1 

2 

3 

4 

1 

2 

3 

4 

5 

6 

7  and  over 

No  report 

Totals 

Fig.  64.     Juvenile  occupants  and  the  house  where  the  mother  was 
tul .crculous.     Ordinarj'  sanitary  facihties  were  lacking  here. 


CONDITION  OF  THE   NATURAL  LIGHTING        185 


TABLE  23 

SHOWING  THE  CONDITION  OF  THE  NATURAL  LIGHTING  IN 
THE   HOMES,   AND    THE   SIZE   OF   THE   ROOMS  — 

BY  WARDS 


Lighting. 

Size. 

Ward 

Total . 

Good. 

Poor. 

Dark. 

No 

report. 

Satisfac- 
tory. 

I'nsatis- 
factory. 

No 

report. 

1 

2 

3 

4 

Total... 

Fig.  65.     A  street  of  fine  homes  in  Muskogee,  where  excellent  hous- 
ing conditions  prevail. 


186 


HOUSING 


TABLE  24 

SHOWING  THE  SOURCE  OF  WATER  USED  ESSENTIALLY  FOR 

DRINKING   PURPOSES   AND    THE   NUMBER   OF   HOMES 

WHERE   WATER   IS   BOUGHT  —  BY   WARDS 

Water  facilities. 


Ward. 

Total. 

Cistern. 

Well. 

Public 
supply. 

Cistern 

and 
public 
supply. 

Well 

and 

public 

supply. 

No 
report. 

Bought. 

Yes. 

No. 

1 

2 

3 

4 

Total.. 

TABLE  25 

SHOWING  THE  METHOD  OF  SEWAGE-DISPOSAL  EMPLOYED 

—  BY  WARDS 


Ward. 

Total. 

ii^ewer. 

Cess- 
pool. 

8ewer  on 
street. 

No  sewer 
on  street. 

No 
report. 

No 
report. 

1 

2 

3 

4 

Total 

DISTRIBUTION  OF  HOMES 


187 


TABLE  26 

SHOWING  THE  METHOD  OF  GARBAGE-DISPOSAL 
EMPLOYED  — BY  WARDS 


Disposal  of  garbage  by 

Total  in 
ward. 

Ward. 

i 

City. 

Chick- 
ens. 

Burn- 
ing. 

Dumping 
in  yard. 

Other 
methods. 

No 
leport. 

1 

2 

3 

4 

Total.... 

TABLE   27 

SHOWING  THE  DISTRIBUTION  OF  HOMES  ACCORDING  TO 
THE   COLOR   OF   THE   RESIDENTS  —  BY  WARDS 


Total  in 
ward. 

Color  of  resident. 

No  report. 

Ward. 

White 

Colored. 

1 

2 

3 

4 

1 

Total 

188  HOUSING 

The  Tables  should  be  Thoroughly  Discussed  and 
Graphically  Illustrated.  —  Each  table  should  form  the 
basis  for  a  discussion  of  a  distinct  and  specific  phase  of  the 
housing;  situation.  The  surveyor  should  not  only  state 
the  facts  represented  by  the  figures,  but  should  also  criticize 
the  existing  conditions  in  so  far  as  they  need  criticism, 
and  should  offer  suggestions  for  the  solution  of  the  ills 
that  have  been  found.  The  final  report  should  also  include 
a  number  of  charts.  One  of  these  should  show  the  condi- 
tion of  the  dwellings,  by  wards;  another,  the  number  of 
rooms  per  house,  by  wards;  another,  which  should  prefer- 
ably be  in  the  form  of  a  graph,  should  show  the  relation- 
ship between  the  number  of  rooms  and  the  prevailing 
family  in  each  ward.  This  may  be  a  family  of  three,  four, 
or  five,  or  even  more.  Another  chart  should  show^  the 
proportion  of  homes  buying  water,  by  wards;  and  another, 
the  prevalence  of  privies  and  wells,  by  wards. 

OUTLINE   OF   CHAPTER   ON   HOUSING 

1.  General  impression  of  housing  situation  in  city. 

2.  How  housing  survey  was  organized  and  conducted. 

3.  Card  used  for  collecting  data. 

4.  Analysis  of  housing  information  obtained. 

5.  Inspection  of  rooming-houses. 

6.  Nuisances  due  to  exposed  garbage,  exposed  manure,  empty  cans, 
rainwater  barrels,  pools,  etc.,  live-stock,  unprotected  privies. 

7.  Discuss  results  of  analysis,  emphasizing  overcrowding,  water 
facilities,  toilet  facilities,  screening  of  doors  and  windows,  method  of 
garbage-disposal. 

8.  Photographs  and  more  thorough  description  of  some  of  the 
scenes. 

9.  Comparisons  with  other  cities  if  similar  data  are  available. 

10.  vSummary. 

11.  Recommendations. 


CHAPTER  XI 
SCHOOL   SANITATION 

The  Sanitation  of  Modern  School  Buildings  is  Excellent. 

—  Until  within  the  past  two  decades,  comparatively  little 
attention  was  given  to  the  sanitary  conditions  under  which 
our  children  received  their  education  in  the  public  schools. 
The  primary  object  of  the  schools  was  to  teach  the  child 


Fig.  66.     The  high  school  in  Enid,  Okla.,  where  the  sanitary  condi- 
tions were  excellent. 

the  elements  of  reading,   writing  and  arithmetic,  together 

with   such   subjects   as  history,    geography  and  grammar. 

Very  little   thought  was  given  to  the  health  of  the  child, 

or  to  the  effect  which  the  school  environment  had  on  his 

welfare. 

189 


190 


SCHOOL  SANITATION 


Except  in  the  rural  schools,  which  usually  suffer  from 
inadequate  financial  support,  this  condition  has  been 
greatly  modified  during  recent  years.  The  modern  school 
buildings  stand  as  worthy  monuments  to  the  American 
interest  in  education.  They  are  designed  to  yield  the 
maximum  of  comfort  and  convenience;  they  are  artistic, 
and  are  usually  well  located  and  built  of  fire-proof  material. 


III 


i 


■•« 


1^.^        •  . .  ^ 

Fig.  67      A  model  junior  high  school  in  Bartlesville,  Okla.,  which 
was  satisfactory  in  every  way. 

Adequate  stairway  facilities  are  furnished,  and  only  fire- 
proof material  is  used  in  their  construction.  The  rooms 
are  large,  light  and  airy;  care  is  taken  to  allow  the  natural 
light  to  enter  the  room  from  the  left,  and  artificial  lighting 
is  provided  in  each  room,  for  use  on  dull  days.  The  seats 
and  desks  are  adjustable,  and  are  usually  adjusted  for 
each  pupil,  once  every  term.  The  window-shades,  which 
are  generally  satisfactory,  are  sometimes  attached  at  the 
bottom  of  the  window  and  drawn  upward,  so  as  to  allow 
the  light  to  enter  the  room  near  the  ceiling.  In  other  cases, 
the  shades  can  be  raised  from  the  bottom  and  lowered 
from  the  top,  in  order  to  permit  top  and  bottom  lighting 


HEATING  AND   VENTILATION  191 

simultaneously,  when  this  is  thought  desirable.  In  still 
other  cases,  each  window  has  two  shades,  one  of  which  is 
drawn  upward  from  the  middle  of  the  window,  and  the 
other  downward.  In  this  case  it  is  possible  to  keep  the 
windows  open  without  causing  the  shades  to  flap. 

The  Heating  and  Ventilation  of  Class-Rooms.  —  Every 
room  in  a  modern  school  building  is  artifically  heated  and 
ventilated.  In  some  cases,  the  heating  system  is  combined 
with  the  ventilating  system,  the  air  being  heated  by  pass- 
ing over  steam  coils,  after  which  it  is  driven  into  the  room 
by  a  huge  revolving  fan.  Sometimes  the  heated  air  is 
removed  from  the  room  by  suction,  but  this  is  not  always 
the  practice.  Some  school  buildings  have  steam  heat  or 
hot-water  heat  as  independent  heating  units.  In  some 
instances,  artificial  ventilation  is  not  practised  at  all,  the 
rooms  being  ventilated  by  means  of  open  windows  and 
air  deflectors  which  are  placed  at  an  angle  at  the  base  of 
each  window. 

From  the  experience  of  the  author,  it  would  seem  that 
artificial  ventilation  in  the  schools  is  expensive,  and  rarely 
productive  of  satisfactory  atmospheric  concUtions  in  the 
class-rooms.  Equally  good  and  even  better  air  conditions 
can  often  be  secured  without  it.  The  schools  are  usually 
located  in  desirable  places,  and,  except  in  the  very  large 
cities,  are  not  hemmed  in  on  all  sides  by  towering  build- 
ings. Even  in  large  cities,  the  schools  are  frequently  free 
from  these  obstructions,  either  on  account  of  the  large 
open  spaces  around  them,  or  the  practice  of  erecting  school- 
buildings  with  large  courts.  It  is  therefore  obvious  that 
in  almost  every  case  the  building  will  receive  a  plentiful 
supply  of  fresh  air,  which  will  be  available  to  every  room, 
without  being  driven  in  by  a  centrally  located  ventilating 

fan. 

The  advantages  of  natural  ventilation  are  several.  Its 
comparative  cheapness  is  evident,  since  no  energy  is  ex- 


192 


SCHOOL  SANITATION 


pended  in  driving  the  air  into  tne  room,  and  there  is  no 
ventilating  system  to  be  installed.  Moreover,  the  air 
supplied  to  the  rooms  is  not  dried.  Where  the  plenum 
system  is  employed  and  the  air  is  heated  before  it  is  sent 
into  the  rooms,  its  relative  humidity  is  greatly  diminished. 


Fig.  68.  A  window-ventilated  schoolroom  at  Fairfield,  Conn. 
Notice  the  plates  which  deflect  the  air  upward  and  the  long  radiators 
under  the  windows.  (Reprinted  with  permission  of  Professor  C.-E.  A. 
Winslow.) 

As  a  rule,  the  loss  in  relative  humidity  is  not  supplemented 
by  additional  humidification,  so  that  the  class-room  air 
is  exceedingly  dry,  and  therefore  undesirable  and  injurious. 
Where  natural  ventilation  is  in  use,  this  condition  never 
exists,  as  the  air  is  not  heated  to  the  same  temperature  as 
with  the  plenum  system.     The  loss  in  relative  humidity 


HEATING  AND  VENTILATING  193 

can  be  replaced,  to  a  great  extent,  by  exposing  large,  shallow 
pans  of  water  on  the  radiators  in  the  room,  or  by  humidify- 
ing the  air,  after  it  has  been  heated  and  before  it  is  sent 
into  the  room. 

It  is  also  true  that  naturally  ventilated  rooms  are  not 
usually  as  warm  as  those  into  which  heated  air  is  driven. 
The  heating  and  ventilating  systems  of  a  school  are,  as  a 
rule,  under  the  supervision  of  the  janitor,  whose  knowledge 
of  good,  hygienic  heating  and  ventilation  is  usually  meagre. 
His  aim  is  to  keep  the  temperature  of  each  room  at  68°  or 
70°  F.  It  seldom  falls  below  this  in  artificially  ventilated 
school-rooms  which  generally  vary  from  70°  to  78°  F,,  and 
are  sometimes  even  warmer.  With  natural  ventilation 
there  will  be  a  greater  variation  in  temperature  in  the 
class-room,  due  to  the  variation  of  the  temperature  out  of 
doors.  This  variation  is  gradual  and,  far  from  being 
injurious,  is  very  beneficial,  since  it  serves  to  stimulate 
the  children  both  physically  and  mentally.  The  tempera- 
ture of  naturally  ventilated  rooms  usually  varies  between 
60°  and  68°  F.,  and  seldom  exceeds  68°  or  70°  F.,  except 
when  the  out-door  temperature  is  greater.  This  range  of 
temperature  is  much  more  beneficial  to  the  children  than 
a  higher  one. 

Natural  ventilation  may  be  employed  either  through  the 
use  of  windows  alone,  or  through  the  combined  use  of 
windows  and  air-ducts,  the  latter  leading  from  the  outside 
through  one  of  the  walls  and  entering  the  room  near  the 
ceiling.  The  presence  of  such  ducts  provides  for  a  constant 
fresh  air  supply,  since  the  inside  of  the  building  is  usually 
warm,  and  the  warm  air  rising  in  these  ducts  will  cause 
cooler  air  to  flow  through  the  windows  into  the  room. 
Where  windows  alone  are  used,  they  are  opened  both  at 
the  top  and  at  the  bottom.  The  fresh  air  enters  near  the 
bottom,  and  the  foul  air,  which  is  warmer  and  lighter, 
rises  and  escapes  at  the  top.     Where  air  ducts  are  installed, 


194  SCHOOL  SANITATION 

the  warm,  foul  air  passes  out  through  them.  An  outward 
draft  may  be  created  in  the  air  duct  by  burning  several  gas 
jets;   and,  in  this  way,  air  circulation  may  be  insured. 

In  naturally  ventilated  rooms,  the  air  conditions  depend 
entirely  on  the  intelligence  of  the  teacher.  Where  the 
plenum  system  is  used,  the  condition  of  all  the  rooms  is 
dependent  on  the  inteUigence  and  interest  of  the  janitor. 
It  is  probably  true  that  the  air  conditions  in  most  of  the 
rooms  will  be  better  under  the  individual  supervision  of 
the  teachers  than  where  the  ventilation  of  the  entire  school 
is  dependent  on  one  man  who  can  rarely  give  the  matter 
the  time  and  attention  it  requires,  and  who  is  often  not 
the  best  judge  of  what  constitutes  a  desirable  condition. 
The  class-rooms  in  modern  school  buildings  are  furnished 
with  thermometers ;  and,  in  some  cities,  the  observation  of 
temperatures  and  the  keeping  of  temperature  records  are  com- 
pulsory. An  intelligent  teacher  will  use  these  observations 
as  a  guide  for  regulating  the  air  conditions  of  the  room. 

Other  Sanitary  Improvements  in  Modern  Schools.  — 
Numerous  other  improvements  have  been  introduced  into 
the  modern  schools.  For  example,  each  room  is  provided 
with  a  light,  large,  and  well-ventilated  cloak-room.  The 
toilet  facilities  are  excellent.  The  toilet  seats  are  of  the 
horse-shoe  shape,  which  is  considered  the  most  desirable. 
Excellent  washing  facilities  are  provided,  including  liquid 
or  powdered  soap  and  individual  paper  towels.  The  com- 
mon drinking-cup  has  given  way  to  the  bubbling  fountain; 
and  an  improved  type  of  fountain,  which  prevents  the 
washings  of  the  mouth  from  coming  into  contact  with  the 
orifice  of  the  bubbler,  is  now  being  introduced.  Satis- 
factory lunch  rooms  are  also  provided;  and,  in  some  cases, 
shower-baths,  swimming-pools  and  elevators  have  also  been 

furnished. 

These  improvements  have  come  about  through  the 
realization  that  the  promotion  of  the  health,  comfort  and 


THE   UNIT   PLAN   OF   SCHOOL   BUILDINGS       195 

physical  welfare  of  the  children  must  go  hand  in  hand  with 
their  education.  A  healthy,  normal  child  can  make  better 
progress  than  one  who  is  dull,  undernourished  or  sick. 
Unfortunately,  however,  there  are  numerous  schools 
throughout  the  country,  and  especially  in  the  rural  dis- 


Fig.  69.  A  satisfactory  bubbling  fountain  where  streams  of  water 
are  emitted  radially  and  meet  in  the  center  to  form  a  large  bubble. 
The  mouth  washings  do  not  contaminate  the  orifices. 

tricts,  where  the  old  order  of  things  still  exists,  w^here  the 
common  drinking-cup,  the  open  privy,  the  poorly  heated 
room,  and  unsuitable  seats  may  still  be  found.  Where 
these  conditions  prevail,  much  can  be  done  by  bringing 
light  to  those  who  are  responsible. 

The  Unit  Plan  of  School  Buildings.  —  One  of  the  newest 
and  most  unique  developments  in  school  buildings  can  be 
found  in  Tulsa,  Oklahoma.  Most  of  the  schools  in  that 
city  are  built  on  the  unit  plan,  and  are  as  nearly  perfect 
as  it  is  possible,  at  present,  to  make  them.  The  entire 
school  consists  of  a  series  of  one-story  stone  buildings, 
built   around   a   large   rectangular   playground,    about   an 


196  SCHOOL  SANITATION 

acre  in  area.  Each  one-story  buildino;  contains  two  rooms, 
each  opening  out  into  the  playground  and  arranged  in 
such  a  way  that  the  Hght  enters  from  the  left,  in  evory 
case.  Each  room  has  separate  toilets,  separate  washing 
facilities  and  separate  cloak-rooms  for  the  boys  and  girls. 
The  rooms  are  ventilated  by  the  use  of  windows,  and  by 
air  ducts  which  carry  off  the  foul  air.  They  are  heated 
by  steam,  the  radiators  being  near  the  windows.  The 
shades  are  perfectly  satisfactory,  and  artificial  lighting  is 
supplied  in  every  room.  The  seats  and  desks  are  adjust- 
able, and  the  blackboards  are  made  of  slate.  The  danger 
from  fire  is  practically  eliminated.  There  are  two  two- 
story  structures  which  are  opposite  each  other,  and  around 
which  the  other  buildings  are  erected.  One  of  these  is 
used  as  an  administration  building  and  also  contains  the 
gymnasium,  while  the  other  is  used  for  classes  in  domestic 
science  and  mechanic  arts.  The  walk  which  encircles  the 
playground  is  covered  by  a  concrete  roof,  in  order  to  afford 
protection  from  rain,  and  also  to  shade  that  side  of  each 
building  on  which  the  light  is  not  needed.  In  order  to 
insure  good  light  in  the  class-rooms  during  all  hours  of 
the  day,  each  room  has  two  small  windows  opposite  the 
large  windows  and  over  the  roof  of  the  walk. 

This  type  of  school  building  is  the  best  which  the  author 
has  seen  anywhere.  Where  sufficient  room  is  available, 
and  the  community  is  able  to  meet  the  cost  of  construction, 
the  unit  type  seems  to  be  the  most  desirable  form  of  school 
building. 

The  Health  Surveyor  should  Study  the  Sanitary  Condi- 
tions in  All  the  Schools.  —  Because  so  much  of  the  life  of 
the  child  is  spent  in  the  environment  of  the  school,  the 
conditions  which  prevail  there  are  of  great  interest  to  the 
public  health  worker,  in  so  far  as  they  affect  the  health, 
comfort  and  welfare  of  each  child.  The  health  surveyor 
should,   therefore,   visit   every   school,   and   make   a   very 


Fig.  70.  A  bubbling  fountain  in  one  of  the  Tulsa  schools,  where 
running  water  is  not  available  for  drinking  purposes.  This  does  away 
with  the  use  of  the  common  drinking-cup.  (197) 


198 


SCHOOL  SANITATION 


thorough  study  of  the  sanitary  conditions  and  faciHties, 
He  should  start  with  the  basement,  studying  the  heating 
and  vcntihiting  systems,  the  toilets,  the  washing  facilities, 
the  drinking  facilities  and  the  lunch  room,  after  which  he 
may  proceed  to  study  the  conditions  in  each  room.  In 
this  way,  he  will  gain  a  thorough  knowledge  of  the  environ- 
ment of  the  child  in  the  school.  Permission  should  be 
obtained,    from    the    superintendent    of    schools,    to    visit 


Fig.  71.  The  "shoot  the  chute"  fire  escape  used  at  some  schools  as 
a  means  of  safe  and  rapid  exit  during  emergencies.  Children  slide 
down  the  spiral  chute  into  the  yard. 

every  school  building;  and  if  it  is  possible,  the  surveyor 
should  be  accompanied,  on  his  tour  of  inspection;  by  one 
of  the  officials  of  the  department  of  education  or  by  a 
disinterested  member  of  the  community  who  knows  the 
location  of  each  school.  It  is  also  important  to  have  a 
means  of  conveyance,  as  this  will  save  much  time  and 
energy. 

The  information  which  should  be  obtained  about  each 
school  is  outlined  in  the  following  questions. 


HEATING  AND  VENTILATION 


199 


The  School  Building.  —  What  is  the  name  of  the  school  ? 
When  was  it  built?  Of  what  material  is  it  constructed? 
Is  it  fire-proof?  Are  fire-proof  stairs  provided?  How 
many  stairways  are  provided?  In  what  portions  of  the 
building  are  they  located?  Are  fire-escapes  provided? 
Are  fire-chutes  provided?  How  many  stories  are  there? 
Is  the  school  provided  with  an  out-door  playground?  Is 
the  location  quiet  and  pleasant?  How  many  class-rooms 
are  there?  How  many  boys  attend  the  school?  How 
many  girls? 


Fig.  72.  A  water  trough  with  three  faucets  on  either  side  used  to 
distribute  water  to  the  school  children  in  Bartlesville,  Okla.  Many 
children  drink  directly  from  the  faucets. 

Heating  and  Ventilation.  —  How  is  the  school  heated  ? 
Is  it  equipped  with  a  central  heating-plant?  Describe  the 
method  of  heating  employed.  Are  the  rooms  artificially 
ventilated?  What  system  of  ventilation  is  employed? 
Are  the  heating  and  ventilating  systems  combined?  Who 
is  responsible  for  the  control  of  both  systems?  What  is 
his  position?     Is  a  constant  temperature  maintained  in 


200 


SCHOOL  SANITATION 


the  rooms?  If  so,  is  a  thermostat  arrangement  employed 
for  this  purpose?  What  is  the  temperature  that  is  main- 
tained ?  Where  are  the  inlets  and  outlets  located  ?  What 
is  the  size  of  each?  What  precautions  are  taken  to  dis- 
tril)ute  the  air  uniformly  in  the  rooms?  Is  there  any 
portion  of  the  room  which  does  not  receive  an  ample  supply 
of  incoming  air,  due  to  faulty  distribution?  Is  the  air 
humidified  before  it  is  sent  to  the  rooms?  Is  the  air 
humidified  at  any  time?  Where  is  the  air  intake  located? 
If  near  the  ground,  are  any  precautions  taken  to  remove  the 
dust  from  the  air?  Is  the  heating  system  supplemented  by 
any  additional  method  of  heating,  either  local  or  central? 


Fig.  73.  The  pail  and  common  dipper  still  in  use  in  some  schools 
for  distributing  water. 

If  artificial  ventilation  is  not  employed,  are  the  windows 
used  to  ventilate  the  rooms?  Are  the  windows  kept  open 
both  at  the  top  and  at  the  bottom  ?  Are  window  deflectors 
employed?  Are  air-ducts  used  to  carry  off  the  foul  air? 
If  so,  are  artificial  means  employed  to  create  a  current  in 
the  duct,  in  order  to  lead  the  foul  air  out  ? 


TOILET  AND  WASHING  FACILITIES 


201 


Is  there  a  tnermometer  in  each  room?  Is  it  properly 
located?  Are  periodic  temperature  readings  taken?  Are 
these  readings  recorded?  If  so,  study  the  past  records  in 
order  to  observe  the  temperatures  which  are  usually  found. 

Are  the  teachers  required  to  keep  their  windows  closed 
throughout  the  day?  Are  the  teachers  required  to  air  the 
room  thoroughly  during  the  day?  How  often  is  the  room 
aired?  What  is  the  duration  of  each  period  devoted  to 
this  purpose?  Are  the  children  out  of  the  room  at  that 
time?  If  not,  do  they  perform  any  physical  exercises 
during  these  periods? 


Fig.  74.  Drinking  facilities  in  use  at  a  public  school.  The  barrel 
is  filled  with  city  water  and  showed  much  dirt  when  inspected.  During 
the  winter  the  water  in  the  faucet  freezes.  The  children  then  use  the 
common  dipper  as  a  drinking-cup. 

Toilet  and  Washing  Facilities.  —  Where  are  the  toilets 
located?  How  many  toilet  seats  are  available  for  the 
boys?  How  many  for  the  girls?  Are  the  toilets  private 
or  semi-private,  or  is  privacy  absent  altogether?     Of  what 


202 


SCHOOL  SANITATION 


material  is  the  toilet  seat  made?  Are  the  toilet  seats 
open  in  the  fore-middle  portion?  Is  each  toilet  compart- 
ment supplied  with  paper? 

How  many  urinals  are  available?  Of  what  material 
are  they  made?  Are  they  made  of  impervious  material? 
Are  the  urinals  semi-private,  or  is  no  privacy  provided? 

Arc  the  toilets  and  urinals  connected  to  the  sewer? 
How  often  are  they  flushed?  Is  the  flushing  of  each  toilet 
controlled  locally,  or  are  all  the  toilets  flushed  periodically  ? 
In  the  latter  case,  how  often  are  they  flushed? 


Fig.  75.  The  type  of  drinking  can  used  in  the  public  schools  of  a 
large  city.  Children  as  a  rule  do  not  have  individual  drinking-cups, 
nor  are  such  cups  provided  by  the  school  authorities.  Many  children 
drink  from  the  faucets.  Diseases  like  tuberculosis,  diphtheria,  scarlet 
fever,  measles,  mumps  and  whooping  cough  and  others  may  be  trans- 
mitted in  this  way.  The  drinking  can  should  be  abandoned,  and  safe 
and  satisfactory  drinking  fr.cilities  substituted. 

How  many  touets  are  in  poor  repair?  Is  the  toilet- 
room  large,  light  and  airy?  Are  the  toilets  and  urinals 
ventilated?     Are  foul  odors  detectable?     Does  any  other 


DRINKING  FACILITIES 


^03 


nuisance  exist?  Is  the  floor  made  of  impervious  material? 
Is  it  fitted  with  a  drain  connecting  with  the  sewer? 

If  privies  are  in  use,  obtain  as  much  of  the  above  informa- 
tion as  would  apply  to  them,  and,  in  addition,  determine 
whether  or  not  the  privies  are  fly-tight  and  sanitary. 

Are  washing  facilities  provided  with  the  toilets?  If  so, 
is  warm  water  provided?  In  what  form,  if  any,  is  soap 
supplied  —  powdered,  liquid  or  cake?  Are  individual 
towels  provided?  Are  they  made  of  paper  or  of  cloth? 
Is  a  common  towel  provided  ?     Are  towels  entirely  absent  ? 


Fig.  76.  A  safe  and  sanitary  bubbling  fountain,  which  does  not 
permit  the  bubbler  to  become  infected  with  the  mouth  washings.  Only 
bubblers  of  this  type  should  be  employed. 

Drinking  Facilities.  —  What  method  is  in  use  for  dis- 
tributing water  to  the  children?     What  is  the  source  of 


204 


SCHOOL  SANITATION 


the  water?  Is  it  considered  safe?  If  there  is  any  doubt, 
bacteriological  analyses  should  be  made.  Is  the  water 
treated  in  any  way  before  the  children  get  it?  If  so, 
describe  the  method  in  detail.  Are  bubbling  fountains 
employed?  If  so,  how  many  bubblers  are  available? 
Are  the  fountains  so  designed  that  the  washings  from  the 
mouth  do  not  come  into  contact  with  the  orifice  of  the 
bubbler?  Are  individual  drinking-cups  provided,  in  case 
bubblers  are  not  in  use?  If  bubblers  are  not  in  use, 
describe  in  detail  the  method  employed  for  distributing 
water  to  the  children. 


Fig.  77.  Lunch  room  and  cafeteria  availanle  now  in  many  hijih 
schools  where  the  children  can  obtain  wholesome  food  at  reasonable 
prices  and  eat  under  very  satisfactory  conditions. 


Lunch  Rooms.  —  Are  lunch  rooms  provided  ?  Where 
are  they  located?  Are  the  rooms  large,  light  and  airy? 
Are  chairs  and  tables  provided?  Is  provision  made  for 
obtaining  warm  food  or  warm  drinks?  Is  food  of  any 
kind  offered  for  sale?  Is  the  lunch  room  heated  during 
cold    weather?     Are    refuse    receptacles    provided?     Are 


SEATS,   LIGHTING  AND  SHADES 


205 


the  lunch  rooms  conveniently  located  with  regard  to  the 
washing  and  drinking  facilities? 

The  Classrooms :  Seats,  Lighting  and  Shades.  —  What 
is  the  size  of  each  room?  How  many  seats  are  provided? 
Are  they  individual  seats?  How  many  children  are  there 
in  each  class?  Does  overcrowding  exist?  Are  the  seats 
and  desks  adjustable?  If  so,  how  often  are  they  adjusted? 
Who  does  the  adjusting?  What  is  his  position?  What 
rule  is  employed  in  regulating  the  height  of  seats  and 
desks?  From  what  direction  does  the  natural  light  come? 
How  many  windows  has  each  room?  What  is  the  ratio 
of  window  area  to  floor  area? 


Fig.  78.  The  TuLsa  High  School  equipped  with  every  modern  con- 
venience and  a  model  of  its  kind. 

Are  window-shades  provided?  What  color  are  they? 
How  do  they  operate?  Are  they  in  good  condition?  Do 
they  cover  the  whole  window,  so  that  beams  of  light  do 
not  shine  across  the  room,  when  they  are  drawn? 

Is  artificial  light  provided?  What  is  its  nature?  If 
electric   light   is   used,   how   many   bulbs   are   employed? 


206  SCHOOL  SANITATION 

Are  they  distributed  so  that  the  room  may  be  uniformly 
lighted  ? 

Of  what  material  are  the  blackboards  made?  Are  they 
satisfactory? 

If  the  rooms  and  windows  are  not  measured,  determine 
whetlier  they  appear  to  be  large,  light  and  airy. 

Cloak-Rooms.  —  Is  each  room  supplied  with  a  private 
cloak-room?  Are  the  cloak-rooms  large,  light,  and  well 
ventilated?  Are  individual  hooks  provided?  Are  there 
any  facilities  for  storing  rubbers  and  umbrellas?  What 
method  is  employed  for  distributing  the  clothing  when  the 
classes  are  dismissed? 

General  Information  that  should  also  be  Obtained.  — 
In  studying  the  schools,  it  is  also  desirable  to  obtain  some 
information  regarding  the  age,  sex  and  race  distribution 
of  the  children.  Information  relative  to  the  use  and  fre- 
quency of  fire-drills  and  the  presence  of  a  fire-alarm  system 
in  the  Iniilding  should  also  be  obtained.  The  methods  of 
cleaning  rooms  and  blackboards  should  also  be  noted. 
Dry  sweeping  is  ol^jectionable.  Wherever  possible,  vacuum 
cleaners  should  be  employed,  and  in  other  cases,  moist 
sweeping  should  be  practised.  The  blackboards  should 
also  be  washed  instead  of  being  dry  rubbed.  These  prac- 
tices diminish  the  amount  of  dust  in  the  air  and  on  the 
various  objects  in  the  room.  The  surveyor  should  also 
ascertain  whether  the  schools  are  regularly  inspected,  by 
whom  the  inspections  are  made,  and  the  frequency  of  the 
inspections.  If  any  records  are  available,  they  should  be 
examined  by  the  surveyor. 

The  following  table  will  serve  to  summarize  most  of  the 
important  facts  which  should  be  brought  out  during  the 
survey  of  the  school  buildings. 


OUTLINE   OF  CHAPTER 


207 


TABLE   28 
SUMMARY   OF   INSPECTION   OF   SCHOOL   BUILDINGS 


Name  of 
school. 

Construc- 
tion. 

1 
1 

Stories. 

1 

Is  building 
fireproof? 

Fire- 
escapes  or 
fire-chutes 
provided. 

Number 
of  class- 
rooms. 

Adjustable 

seats. 

Method  of 
heating. 

Artificial 
ventilation. 

Drinking 
facilities. 

Toilet  facilities. 

Washing 

facilities 

provided. 

Paper 

Connected 
to  sewer. 

Condition. 

towels 
supplied. 

i 

When  the  surveyor  is  writmg  his  final  report,  the  follow- 
ing outline  will  help  him  to  recall  the  items  covered  during 
the  survey  of  the  schools. 

OUTLINE   OF   CHAPTER   ON    SCHOOL   SANITATION 

1.  The  importance  of  satisfactory  sanitary  conditions  in  the  schools 
for  the  health,  comfort  and  welfare  of  the  children. 

2.  Inspection  of  the  schools. 


208  SCHOOL  SANITATION 

3.  Consideration  of  the  following  factors:  location;  height;  mate- 
rial used  in  construction;  stairways;  safety  of  the  building  as  regards 
fire;  fire-drills;  playground  facilities;  heating  and  ventilation;  toilet 
facilities;  drinking  facilities;  washing  facilities;  lunch  room  facilities; 
lighting,  natural  and  artificial;  window-shades;  blackboards;  cloak- 
room facilities;  overcrowding;  age,  sex  and  race  distribution  of  chil- 
dren; special  features. 

4.  Discussion  of  the  findings. 

5.  Summary. 

6.  Recommendations. 


CHAPTER   XII 
SCHOOL  HYGIENE 

The  Role  of  the  School  Nurse.  —  Coincident  with  the 
development  of  public  interest  in  the  sanitation  of  schools 
and  the  welfare  of  the  school-children  came  the  recogni- 
tion that  much  could  actually  be  accomplished  for  the 
health  of  the  children  by  placing  them  under  expert  medical 
and  nursing  supervision.  As  a  result,  school  nurses  were 
employed,  not  only  to  detect  the  symptoms  of  the  common 
diseases  of  childhood,  but  also  to  render  first  aid  when 
necessary,  to  follow  the  children  into  their  homes,  to 
instruct  the  mother  in  the  precautions  necessary  to  pre- 
vent the  spread  of  disease  and  in  the  proper  care  of  the 
child,  especially  during  the  period  of  illness.  They  were 
also  intended  to  help  in  other  ways,  such  as  by  informing 
the  mother  of  the  available  community  agencies  that  may 
benefit  her  child,  and  actually  making  it  possible  for  her 
to  obtain  the  necessary  aid  from  these  agencies.  The  pub- 
lic health  nurse  is  undoubtedly  one  of  the  most  important 
factors  in  combating  and  controlling  disease.  Without  her 
aid,  the  public  health  campaign  could  not  make  the  progress 
it  has  made.  She  is  the  direct  link  between  the  people 
and  the  health  department;  and  it  is  she  who  carries  the 
message  of  healthy  living  into  the  home,  not  only  by  talks 
and  demonstrations,  but  also  through  the  sheer  force  of 
her  personality  and  kindly  interest. 

The  Role  of  the  School  Physician.  —  After  the  intro- 
duction of  the  school  nurse  came  the  school  physician. 
He  visits  the  school  frequently,  makes  periodic  medical 
examinations  of  each  child,  records  the  findings  on  a  card 

209 


210  SCHOOL  HYGIENE 

which  follows  the  child  throughout  his  career  in  school, 
makes  more  frequent  examinations  of  those  children  who 
are  referred  to  him  by  the  school  nurse  or  the  teacher,  and 
attempts  in  this  way  to  prevent  disease  and  to  correct 
physical  and  mental  defects. 

Reasons  for  Inadequate  Health  Protection  of  School 
Children.  —  The  purpose  of  school  hygiene  is  to  prevent 
the  spread  of  the  diseases  of  childhood  and  to  correct  such 
mental  and  physical  defects  as  may  be  discovered  in  the 
children.  The  work  of  the  school  nurse  and  the  school 
physician  has  doubtless  accomplished  much  along  these 
lines;  but  a  glance  at  the  vital  statistics  of  any  community 
will  show  that  the  communicable  diseases  of  childhood  are 
still  very  prevalent.  This  is  true  for  several  reasons.  In 
the  first  place,  the  children  are  under  the  control  of  the 
medical  department  of  the  schools  for  only  a  portion  of  the 
day;  before  and  after  that  they  are  in  contact  with  each 
other  and  with  adults.  In  the  second  place,  the  medical 
inspection  and  school  nursing  are  sometimes  very  inade- 
quate, and  the  children  are  examined  very  infrequently. 
This  may  be  due  to  the  fact  that  the  school  physician  is 
a  part-time  employee,  and  the  school  nurse  has  too  many 
children  under  her  care.  Inadequate  transportation  facili- 
ties may  also  prevent  her  from  reaching  and  inspecting 
each  child. as  frequently  as  she  should.  In  the  third  place, 
the  physician  may  not  be  properly  trained  for  his  work 
and  his  examinations  may  be  superficial.  Similarly,  the 
school  nurse  may  be  temperamentally  unfit  for  her  work, 
or  may  not  have  been  properly  trained  for  it.  There  are 
also  difficulties  of  administration,  and  the  possibility  of 
objections  on  the  part  of  school  authorities,  if  the  health 
work  interferes  too  much  with  educational  work.  The 
author  believes,  however,  that  it  is  possible  to  curb  disease 
and  physical  defects  in  children  to  a  greater  degree  than 
has  been  accomplished  up  to  the  present  time,  by  increas- 


THE   HEALTH  OF  THE  CHILD 


211 


ing  the  number  of  school  physicians,  school  nurses,  and 
clinics,  and  by  taking  the  precaution  to  employ  only  those 
who  are  properly  educated  and  trained  for  the  work,  and 
who  are  interested  and  willing  to  give  their  full  time  to  the 
task  of  making  childhood  and  early  youth  as  free  as  pos- 
sible from  disease. 


Fig.  79.  School  children  outside  of  a  one-room  frame  school  build- 
ing which  is  still  very  common  in  certain  sections  of  the  country.  Heat- 
ing, drinking,  toilet  and  seating  facilities  are  usually  very  unsatisfactory 
at  such  schools.     Many  of  the  children  are  too  poor  to  wear  shoes. 

The  Role  of  the  Teacher  in  the  Health  of  the  Child.  — 
Much  good  could  also  be  accomplished  by  the  teacher  if 
she  knew  enough  about  the  elements  of  hygienic  living 
and  the  early  symptoms  of  disease.  The  teacher  is  con- 
stantly with  the  child  during  school  hours,  and  often 
knows  and  understands  the  child  even  better  than  the 
mother.  Neither  the  school  nurse  who  sees  the  children 
only  occasionally,  nor  the  school  physician,  whose  visits 
are  still  more  infrequent,  can  ever  hope  to  know  the  indi- 


212  SCHOOL  HYGIENE 

vidual  child  as  well  or  as  intimately  as  the  teacher  does. 
A  teacher  who  realizes  the  importance  of  good  health  to 
the  children,  who  is  interested  in  their  welfare,  and  who 
has  been  taught  to  recognize  early  symptoms  of  disease  in 
children,  can  do  very  much  to  prevent  sickness  and  even 
death.  Not  only  can  she  help  the  children  who  are  ap- 
parently unwell,  but  by  immediately  segregating  these 
cases  and  placing  them  under  proper  medical  and  nursing 
care,  it  is  likely  that  she  can  protect  others  against  infection. 
It  is  also  true  that  most  of  the  good  habits,  including 
the  hygienic  habits,  are  formed  during  childhood.  Here, 
again,  the  teacher  may  play  the  important  part  of  educator 
and  protector.  Children  should  be  taught  not  to  put 
their  hands  to  the  mouth  or  nose,  or  to  exchange  bites  of 
fruit,  candy  or  other  food.  Children  who  are  not  in  the 
habit  of  washing  their  hands  often,  and  especially  before 
eating,  or  who  do  not  clean  their  teeth  at  least  twice  a 
day,  should  be  instructed  regarding  the  importance  of 
such  practices.  The  teacher  should  be  the  person  respon- 
sible for  the  health  education  of  the  children.  She  should 
not  only  have  regular  lessons  in  hygiene  and  physiology, 
but  should  take  every  opportunity,  regardless  of  the  sub- 
ject under  consideration,  to  correct  the  faulty,  unhygienic 
practices  of  any  child,  and,  in  that  way,  to  teach  the  lessons 
of  hygiene  in  a  practical  manner.  She  should  be  sensitive 
to  the  atmospheric  conditions  in  her  classroom,  to  lighting, 
heating  and  any  other  factor  which  may  affect  the  health, 
comfort  or  welfare  of  the  children.  Teachers  should  not 
feel  that  they  are  only  employed  to  teach  the  three  ''R's," 
history,  geography,  grammar,  etc.  They  should  rather  feel 
that  they  are  helping  to  prepare  the  rising  generation  for 
life.  Education  must  therefore  be  broader  than  mere 
book  knowledge;  it  must  include  the  development  of 
hygienic  habits,  as  well  as  other  virtues,  such  as  industry, 
respect,  reverence,  honesty,  precision,  tidiness,  orderliness, 


PERSONNEL  213 

love  of  beauty  in  all  its  forms,  and  other  qualities  which 
eventually  make  for  a  full,  happy  and  normal  life. 

Other  Agencies  for  the  Health  and  Welfare  of  School 
Children.  —  Besides  the  school  nurse,  the  school  physician 
and  the  teacher,  other  agencies  have  been  developed  for  the 
health  and  welfare  of  the  children.  Dental  clinics,  and, 
more  recently,  nutrition  clinics  have  been  organized. 
School  luncheons  have  been  provided  at  nominal  rates  to 
enable  the  children  of  the  poor  to  obtain  additional  and 
proper  food.  Open-air  classes  have  been  established  for 
children  who  are  anemic  or  who  are  predisposed  to  tuber- 
culosis. Abnormal  and  mentally  defective  children  have 
been  separated  from  the  normal,  and  each  group  has  been 
given  appropriate  treatment. 

Methods  of  Obtaining  the  Data.  —  The  following  ques- 
tions suggest  the  information  which  the  surveyor  should 
obtain.  As  much  as  possible  should  be  learned  from 
available  printed  reports,  supplemented  by  personal  inter- 
views with  the  school  physician,  the  school  nurse,  the 
school  dentist,  the  superintendent  of  schools  and  any- 
body else  who  may  be  expected  to  be  particularly  well 
informed  about  the  health  supervision  of  the  children. 

Personnel 

How  many  school  physicians  are  employed?  By  whom 
are  they  employed?  Is  each  employed  on  a  full  time 
basis?  For  what  period  is  each  employed?  What  is  the 
salary  of  each?  How  many  children  is  each  required  to 
supervise  ? 

How  many  public  health  nurses  are  employed?  By 
whom  are  they  employed?  Is  each  employed  on  a  full 
time  basis  ?  For  what  period  is  each  employed  ?  What  is 
the  salary  of  each?  How  many  children  is  each  required 
to  supervise? 


214  SCHOOL  HYGIENE 

How  many  school  dentists  are  employed?  By  whom 
are  they  employed?  Is  each  employed  on  a  full  time 
basis?  For  what  period  is  each  employed?  What  is  the 
salary  of  each?     How  many  children  is  each  expected  to 

supervise  ? 

Are  any  other  technical  experts  employed  to  supervise 
the  health  of  the  children?  If  so,  in  what  capacity  are 
they  employed?  Are  they  full  time  employees?  What 
is  the  salary  of  each?  How  many  children  is  each  re^ 
quired  to  supervise? 

Is  the  supervision  of  the  health  of  the  children  in  the 
schools  under  the  direction  of  the  health  department,  or 
of  the  Board  of  Education?  If  the  latter,  is  there  any 
provision  for  cooperation  with  the  health  department? 
If  so,  describe  in  detail. 

School  Physician 

Where  is  the  office  of  the  sc  ool  physician  located? 
Are  the  children  examined  at  the  office,  in  special  rooms 
at  the  school,  or  in  the  regular  class-room?  How  often  is 
each  child  examined?  Of  what  does  the  examination 
consist?  Is  each  school  provided  w^th  scales  for  weighing 
the  children?  Are  the  weight  and  height  of  each  child 
determined?  How  often  are  these  tests  performed?  Is 
each  child  examined  for  eye  and  ear  defects?  For  nose 
and  throat  defects?  For  defects  of  the  teeth?  For 
undernourishment  and  anemia?  For  tuberculosis?  For 
defects  of  the  heart?  For  malformation,  for  any  of  the 
quarantinable  diseases,  and  for  mental  and  nervous  dis- 
orders? Are  special  examinations  given  to  children  who 
require  them  ?  Is  each  child  required  to  strip  for  examina- 
tion? Are  the  results  of  each  examination  recorded? 
Does  the  record-card  follow  the  child  throughout  his  school 
career? 


THE  SCHOOL  NURSE  215 

What  steps  are  taken  to  remedy  the  defects  that  are 
discovered?  Is  any  follow-up  work  done  to  see  that  the 
defects  are  remedied?  Who  is  responsible  for  this  phase 
of  the  work?  Is  any  provision  made,  either  by  the  muni- 
cipality or  by  private  agencies,  to  aid  those  children  who 
have  defects,  and  cannot  afford  to  have  them  treated?  If 
so,  describe  the  facilities  which  are  available,  and  determine 
whether  they  are  adequate. 

Does  the  school  physician  visit  each  class  in  order  to 
discover  children  who  are  unusually  pallid,  whose  faces  are 
puffed  or  flushed,  who  show  eruptions  of  any  sort,  or  who 
have  colds  in  the  head,  running  eyes,  sore  throat,  nasal 
discharges,  coughs  and  other  early  symptoms  of  disease? 
If  so,  how  often  are  these  inspections  made?  Are  many 
children  called  out  for  special  examination  as  a  result  of 
these  inspections?  What  has  been  the  result  of  these 
inspections  ? 

The  surveyor  should  obtain  a  record  of  the  number  of 
children  examined  in  a  year,  the  defects  that  were  dis- 
covered, and  the  results  of  the  follow-up  work. 

The  School  Nurse 

Under  whose  direction  does  the  school  nurse  perform  her 
work?  Is  a  special  office  provided?  If  so,  where?  Has 
she  definite  office-hours?  If  so,  what  are  they?  How 
often  does  the  school  nurse  visit  each  class?  Does  she 
examine  the  children  for  early  symptoms  of  disease  ?  Does 
she  refer  any  cases  to  the  attention  of  the  school  physician  ? 
Does  she  perform  any  of  the  tests  required  in  a  thorough 
medical  examination  ?  If  so,  what  tests  does  she  perform  ? 
How  often  is  this  done? 

Does  the  school  nurse  obtain  the  name  of  the  children 
who  are  absent  from  school  each  day  ?  Does  she  determine 
which  children  are  absent  on  account  of  illness  ?     Does  she 


216 


SCHOOL  HYGIENE 


visit  the  homes  of  the  children  who  have  physical  defects, 
in  order  to  convince  the  parents  that  the  defect  ought  to 
be  remedied  immediately?  How  many  home  visits  does 
she  make  during  the  school  year?  Must  each  child  who  is 
ill  obtain  a  certificate  of  health  from  the  health  officer  or  a 
private  physician,  before  being  readmitted  into  the  school? 


Fig.  80.     A  school  dental  clinic  in  operation,  showing  the  dentist, 
the  school  child,  and  the  school  nurse. 

Does  the  school  nurse  aid  the  school  physician?  If  so, 
in  what  manner?  Does  she  aid  the  school  dentist?  If 
so,  in  what  manner? 

Does  the  school  nurse  conduct  tooth-]:)rush  drills?  If 
so,  how  often?  How  are  these  drills  conducted?  Does 
she  examine  the  children  for  scabies,  pediculosis,  ringworm, 
favus  and  impetigo? 

The  surveyor  should  obtain  a  list  of  all  the   cases  of 


THE   TEACHER  217 

communicable  disease  that  have  occurred  among  the 
school-children  during  several  school  years.  Such  a  list 
can  be  obtained  either  from  the  school  physician,  the 
school  nurse,  the  principal,  or  the  superintendent  of  schools. 
The  surveyor  should  also  learn  whether  children  must 
show  a  certificate  of  successful  vaccination  before  being 
admitted  to  the  schools. 

The  School  Dentist 

Is  a  dental  cHnic  maintained?  Where  is  it  located? 
When  was  the  dental  inspection  of  children  begun?  Does 
the  equipment  of  the  dental  clinic  seem  complete  and 
satisfactory?  How  often  are  the  teeth  of  each  child 
examined  ?  What  is.  done  to  remedy  dental  defects  ?  Is 
a  record  kept  of  all  examinations  and  all  repair  work? 
If  so,  the  surveyor  should  obtain  a  list  of  the  inspections 
made  during  several  school  years,  and  also  a  record  of 
the  work  done  to  remedy  the  defects.  Is  any  charge  made 
for  remedying  dental  defects?  If  so,  what  is  the  charge 
for  each  type  of  repair  work  done? 

Is  any  attempt  made  to  educate  the  children  in  oral 
hygiene?  If  so,  what  is  the  nature  of  this  educational 
work?     Describe  it  in  detail. 

Other  Clinics 

If  other  clinics,  such  as  nutrition  clinics,  are  established 
and  in  operation,  the  surveyor  should  visit  them  and,  if 
possible,  obtain  complete  information  about  their  work 
and  accomplishments. 

The  Teacher 

Is  the  teacher  required  to  teach  physiology  or  hygiene 
in  the  class  ?     If  so,  in  what  grade  are  these  studies  begun  ? 


218  SCHOOL  HYGIENE 

In  what  grade  are  they  discontinued?  Is  a  text-l)Ook 
employed?  If  so,  what  is  the  name  of  the  book  and  the 
author?  How  much  time  per  week  is  devoted  to  hygiene 
or  physiology?  Are  the  lessons  in  hygiene  applied  to  the 
daily  lives  of  the  children?  Is  the  teacher  required  to 
inspect  the  children  for  the  early  symptoms  of  disease? 
If  so,  how  many  children  have  been  referred  to  the  school 
physician  or  the  school  nurse  as  a  result  of  these  inspections  ? 
If  the  school  nurse  or  physical  training  teacher  is  re- 
quired to  teach  hygiene  and  physiology,  this  should  be 
noted,  and  the  scope  and  conduct  of  the  work  determined. 

Physical  Training 

Is  physical  training  part  of  the  curriculum?  Is  the 
teacher  in  charge  of  this  work,  or  is  it  placed  under  the 
supervision  of  a  special  instructor?  What  is  the  nature 
of  the  work  in  physical  training?  How  often  do  the 
physical  training  exercises  come?  How  long  does  each 
exercise  last?  Where  is  the  exercise  taken?  Is  the  room 
thoroughly  ventilated  on  such  occasions?  Describe  any 
other  feature  about  the  system  which  may  be  of  interest. 

Private  and  Parochial  Schools 

Since,  in  certain  communities,  the  number  of  children 
attending  private  and  parochial  schools  may  be  consider- 
able, it  is  important  not  only  to  make  a  sanitary  inspection 
of  each  building  occupied  by  such  schools,  but  also  to 
determine  the  nature  and  extent  of  the  system  in  opera- 
tion for  protecting  and  promoting  the  health  of  their  chil- 
dren. It  is  important  therefore  to  include  these  schools 
in  the  study  of  the  public  schools  in  a  community. 


OPEN-AIR  SCHOOLS 


219 


Open-Air  Schools 

How  many  open-air  classes  are  there?  In  what  schools 
are  they  located?  How  many  open-air  schools  are  there? 
Where  are  they  located?  When  was  the  first  open-air 
class  in  the  city  established?  When  was  the  first  open-air 
school  established  ? 


Fig.  81.  An  open-air  class  in  session,  showing  how  the  children  are 
thoroughly  protected  against  inclement  weather.  With  adequate  and 
wholesome  food,  together  with  rest  periods,  anemic  children  thrive 
better  and  learn  more  readily  under  these  conditions. 


How  many  children  attend  the  open-air  classes  or 
schools?  Are  any  of  these  children  actually  tuberculous? 
Are  such  children  segregated  from  those  who  are  not 
tuberculous?  What  are  the  requirements  for  admission 
into  the  open-air  classes  or  schools?  Who  determines 
whether  a  child  shall  be  admitted  or  not?  What  is  the 
capacity  of  each  open-air  class?  Is  each  class  being  used 
to  capacity? 


220  SCHOOL  HYGIENE 

Are  the  children  weighed  and  measured  before  being 
admitted?  Are  they  provided  with  extra  clothing?  Are 
they  provided  with  extra  food?  Are  cots  provided  for 
them?  Who  defrays  the  cost  of  these  additional  require- 
ments? If  possible,  the  surveyor  should  learn  the  cost, 
per  pupil,  of  the  open-air  classes,  and  compare  it  with  the 
cost,  per  pupil,  of  the  regular  classes.  How  many  rest 
periods  during  the  day  does  each  child  have?  What  is 
the  duration  of  each  period?  At  what  intervals  do  they 
occur?     How  often  are  the  children  examined  physically? 

Are  the  open-air  classes  conducted  indoors  or  out-of- 
doors?  If  indoors,  how  many  sides  of  the  room  are  pro- 
vided with  windows?  How  manv  windows  are  there  on 
each  side?  Describe  in  detail  the  equipment  of  each 
room. 

If  the  children  are  fed,  ascertain  the  nature  and  the 
quantity  of  food  that  is  served.  When  is  it  served?  By 
whom  is  it  prepared?  Is  it  served  in  the  class,  or  are  the 
children  required  to  go  elsewhere  for  the  food?  In  the 
latter  case,  ascertain  where  it  is  served,  and  the  distance 
from  the  class-room.  Is  luncheon  served  to  the  children 
at  noon  ?     If  not,  do  they  go  home  for  luncheon  ? 

Does  the  plan  of  work  in  the  open-air  classes  include 
periods  of  exercise?  If  so,  how  often  during  the  day  do 
these  periods  come  ?     What  is  the  duration  of  each  period  ? 

What  results  have  been  obtained  by  the  open-air  treat- 
ment? What  has  been  the  increase  in  weight  of  each 
child?  What  has  been  observed  as  to  the  prevalence  of 
communicable  diseases  among  the  children  in  the  open-air 
classes?  Can  any  comparison  be  made  between  the 
prevalence  of  disease  and  apparent  healthfulness  among 
the  children  in  the  open-air  classes,  and  among  similar 
children  in  the  regular  classes?  If  so,  include  this  in  the 
final  report.  What  mental  progress  do  the  children  in  the 
open-air  classes  make? 


RESULTS  OF  MEDICAL  INSPECTION 


221 


The  -  following  table  may  be  of  value  in  recording  the 
results  of  the  medical  inspection  of  the  school  children. 


TABLE  29 

SOME  RESULTS  OF  THE  MEDICAL  INSPECTION  OF  SCHOOL 

CHILDREN 


Number  of  children  inspected 

Teeth: 

Cavities  discovered 

Cavities  filled , 

Other  dental  defects , 

Vision: 

New  cases  of  defective  vision 

Cases  of  defective  vision  remedied  by  glasses,  and  in 

other  ways , 

Tonsils: 

Cases  showing  enlarged  tonsils .  .,. 

Parents  of  such  cases  notified 

Enlarged  tonsils  removed 

Adenoids: 

Cases  of  adenoids 

Parents  of  such  cases  notified • 

Adenoids  removed 

Cases  of  communicable  disease  among  the  school  children: 

Measles 

Scarlet  fever 

Diphtheria 

Whooping  cough 

Chicken  pox 

Smallpox 

Mumps 

Tuberculosis 

Hookworm 

Scabies 

Pediculosis 

Ringworm 

Favus 

Impetigo 

Conjunctivitis 

Number  of  children  vaccinated 


Year. 


222  SCHOOL  HYGIENE 

OUTLINE   OF  THE   CHAPTER   ON   SCHOOL   HYGIENE 

1.  The  scope  of  school  hygiene  and  its  importance  to  the  welfare 
of  the  children. 

2.  The  roles  of  the  school  physician,  the  school  nurse,  the  school 
dentist  and  the  teacher  in  guarding  and  -Promoting  the  health  of  the 
child. 

3.  The  organization  of  the  school  nygiene  work,  and  the  activities 
of  each  agency  employed  to  promote  the  health  and  welfare  of  the  child. 
Describe  the  scope  of  the  examinations,  their  frequency  and  thor- 
oughness. Describe  also  the  manner  in  which  the  results  are  recorded 
and  utihzed.  Analyze  the  work  of  the  public  health  nurse  in  all  its 
phases.  Similarly  consider  the  work  of  the  school  dentist,  the  open- 
air  classes  or  schools,  the  various  clinics  which  are  held,  and  the  teach- 
ing of  hygiene  in  the  schools.  Discuss  the  defects  thai  have  been 
found  and  the  number  that  have  been  remedied. 

4.  Summary. 

6,  Recommendations. 


CHAPTER  Xin 

ORGANIZATION   AND   ACTIVITIES   OF   THE 
HEALTH   DEPARTMENT 

Health  Department  Activities  often  Inadequate  and 
Inefficient.  —  The  health  department  of  a  community  is 
the  recognized  and  authorized  force  created  and  main- 
tained by  the  municipality,  for  the  preservation  and  pro- 
tection of  the  public  health.  The  organization  and  activi- 
ties of  health  departments  vary  considerably.  Some  are 
highly  organized  and  perform  many  important  functions 
which  tend  to  prevent  disease  and  death.  Others  —  and 
apparently  this  group  comprises  the  great  majority  of 
health  departments  —  are  poorly  organized,  and  do  very 
little  to  protect  the  public  health.  The  health  officers, 
in  such  cases,  usually  confine  their  efforts  to  placarding 
the  house  where  a  case  of  communicable  disease  has  been 
reported,  and  having  the  premises  fumigated  when  the 
disease  has  terminated.  They  also  investigate  nuisances 
which  have  been  brought  to  their  attention,  and  perform 
similar  functions  which  have  but  little  effect  on  the  health 
of  the  general  public.  The  control  of  the  water-supply 
and  other  sources  of  drinking  water  is  neglected.  No 
attempt  is  made  to  make  privies  fly-tight  and  sanitary, 
and  to  cause  the  removal  of  those  that  are  no  longer  neces- 
sary. The  control  of  the  milk-supply  is  seriously  neg- 
lected; inspections  of  dairies  occur  very  infrequently,  and 
laboratory  analyses  are  almost  never  performed.  Restau- 
rants and  food  stores  are  inspected  only  rarely;  and  no 
attempt  is  made  to  supervise  the  sanitation  of  schools  or 

factories. 

223 


224  ACTIVITIES  OF  HEALTH  DEPARTMENT 

The  contagious  disease  hospitals  are,  as  a  rule,  exceed- 
ingly inadequate,  and  unsatisfactorily  managed.  Little 
is  done  to  control  communicable  diseases,  and  epidemics 
sweep  through  the  comnmnity,  leaving  only  the  more 
fortunate  individuals  unscathed.  No  regular,  effective 
use  is  made  of  vaccines  and  sera.     Pubhc  health  education 


Fig.  82.  Tliis  is  the  only  kind  of  health  education  practised  in  a 
city  of  40,000  people.  The  street  corner  vendors  of  patent  medicine 
cures  for  tuberculosis  and  every  other  ill  could  be  seen  at  work  every 
day. 

is  almost  unknown;  and  the  children  in  the  schools  do  not 
receive  the  supervision  they  require.  The  vital  statistics 
are  incomplete,  and  are  studied  only  rarely.  No  attempt 
is  made  to  reduce  the  infant  mortality,  or  the  mortality 
among  children.  Anti-tu])erculosis  and  venereal  disease 
activities  are  entirely  neglected,  or  are  conducted  in  an 
unsatisfactory  manner.  Public  health  nurses  are  either 
not  employed  at  all,  or  else  are  employed  in  insufficient 
numbers.     There  is  very  little  effort  to  combat  the  fly 


OFTEN   INADEQUATE  AND  INEFFICIENT         225 

and  the  mosquito;  and,  in  places  where  hookworm  and 
pellagra  exist,  the  efforts  to  exterminate  these  diseases  are 
conducted  either  through  outside  agencies  or  not  at  all. 

Reasons  for  Poor  Health  Protection.  —  Such  are  the 
conditions  which  prevail  in  many  communities.  They 
may  exist  for  any  of  the  following  reasons:  first,  because 
the  coriimunity  is  not  awake  to  the  necessity  and  possi- 
bility of  protecting  the  public  health  along  modern  lines; 
second,  because  the  appropriation  for  public  health  work 
is  entirely  inadequate;  third,  because  the  personnel  may 
be  poorly  trained;  fourth,  because  the  initiative,  driving 
force  and  other  desirable  human  elements  may  not  be 
present.  It  is  usually  one  of  these  factors,  or  a  combina- 
tion of  them,  which  operates  against  the  development  of 
a  live,  up-to-date  health  organization. 

Health  Officer  should  be  Trained  for  Public  Health 
Work.  —  Many  communities  make  the  serious  mistake  of 
assuming  that  the  physician  is  necessarily  the  one  best 
fitted  to  protect  the  public  health.  The  profession  of  the 
health  officer  is  distinct  from  that  of  the  physician;  and, 
although  both  must  pursue  parallel  studies  for  a  long  time, 
each  also  requires  special  studies.  The  two  professions 
should  therefore  not  be  mistaken  or  confused.  The  health 
officer  should  be  specially  trained  for  his  work,  whether  he 
is  a  physician  or  not;  and  only  one  who  is  so  trained 
should  be  permitted  to  supervise  the  health  of  a  community. 
Moreover,  the  point  of  view  of  the  health  officer  differs 
from  that  of  the  physician.  The  health  officer  must  think 
of  the  whole  community  and  give  particular  attention  to 
the  prevention  of  disease,  while  the  physician  thinks  pri- 
marily of  the  individual  patient  and  of  the  means  of  effect- 
ing a  cure.  Sometimes  a  community  does  not  realize  that 
this  distinction  exists,  and  appoints,  as  a  public  health 
officer,  a  physician  who  has  not  had  the  necessary  training 
for  that  position.     Very  often  the  physician  is  employed 


226  ACTIVITIES  OF  HEALTH  DEPARTMENT 

on  a  part-time  basis.  Such  an  arrangement  is  scarcely 
ever  of  much  value,  as  the  physician's  chief  interest  lies 
in  his  private  practice,  and,  as  a  result,  the  public  welfare 
is  seriously  neglected. 

Health  Appropriation  often  Inadequate.  —  One  of  the 
excuses  most  commonly  given  for  the  inadequacy  of  health 
work  is  the  small  appropriation  available  for  conducting  it. 
There  is  not  the  slightest  doubt  that  this  is  very  often  the 
real  cause  of  the  deficiency.  One  needs  only  to  compare 
the  per  capita  health  appropriation  of  most  communities, 
with  the  per  capita  appropriation  suggested,  by  the  Ameri- 
can Public  Health  Association,  as  the  minimum  require- 
ment for  effective  health  work,  to  realize  how  insufficient 
the  usual  appropriation  really  is.  A  similar  conclusion 
will  be  reached  if  the  per  capita  appropriation  for  health 
work  in  most  communities  is  compared  with  the  per  capita 
appropriation  for  other  municipal  activities. 

From  comparisons  like  these,  it  is  easy  to  realize  that 
public  health  work  often  receives  very  inadequate  financial 
support.  Sometimes  the  appropriation  for  the  care  of  the 
cemeteries,  for  shade  trees,  for  the  parks,  or  for  the  streets 
is  materially  greater  than  that  for  health  work.  It  is  in- 
variably true  that  the  appropriations  for  the  police  depart- 
ment, the  fire  department,  and  the  school  department  are  each 
very  much  greater  than  that  of  the  department  of  health. 

Available  Appropriations  are  not  Always  Properly  Used, 
—  It  is  also  true  that  health  officers,  as  a  group,  are  under- 
paid workers.  Yet,  in  spite  of  the  inadequacy  of  the 
appropriations  and  the  small  financial  return  for  health 
work,  the  deficiency  in  the  number  of  good,  progressive 
health  workers  is  more  often  due  to  personal  ineflficiency 
and  lack  of  training  than  to  any  other  factor.  It  is  doubt- 
ful whether  most  communities  derive  the  greatest  possible 
amount  of  benefit  from  the  money  appropriated  for  health 
work.     Therefore,  although  it  is  important  to  strive  for 


'       ORGANIZATION  AND  PERSONNEL  227 

increased  appropriations,  it  is  equally  important  to  seek 
to  improve  the  personnel  of  the  health  department,  and 
to  derive  as  much  benefit  as  possible  from  the  available 
appropriation. 

Meeting  with  Health  Officer  should  be  Arranged.  — 
During  the  process  of  meeting  the  city  officials,  the  sur- 
veyor will  have  met  the  health  officer.  An  appointment 
for  a  future  meeting  should  be  made,  in  order  that  the 
surveyor  may  obtain  the  necessary  information  about  the 
organization  and  activities  of  the  health  department.  In 
the  meantime  he  should  have  obtained  a  copy  of  the  sani- 
tary code,  which  he  should  study  carefully.  If  possible, 
he  should  also  have  obtained  as  much  knowledge  about 
the  vital  statistics  and  the  activities  of  the  health  depart- 
ment as  can  be  gained  from  previous  reports. 

The  following  questions  will  enable  the  surveyor  to 
obtain  most  of  the  information  he  desires. 

Organization  and  Personnel  of  the  Board  of  Health.  — 
How  many  members  compose  the  board  of  health?  Who 
are  they?  How  are  they  appointed?  What  require- 
ments must  they  meet  before  being  appointed?  What  is 
the  term  of  office  for  each?  What  are  the  powers  of  the 
board  of  health?  What  are  the  duties  of  the  members? 
Are  they  remunerated  for  their  services?  If  so,  what 
remuneration  do  they  receive?  How  often  do  they  meet? 
Are  the  minutes  of  these  meetings  preserved?  If  so,  it 
may  be  to  the  advantage  of  the  su  veyor  to  study  them. 

Organization  and  Personnel  of  the  Health  Department. 
—  Into  what  bureaus  or  divisions  is  the  health  department 
divided?  How  many  persons  are  employed  in  each  divi- 
sion? What  is  the  title  of  each  employee  in  each  division? 
What  remuneration  does  each  employee  receive?  What 
are  the  educational  and  professional  requirements  of  the 
health  officer?  For  what  period  of  time  is  the  health  officer 
appointed?     By  whom  is  his  appointment  made?     Who 


228  ACTIVITIES  OF  HEALTH  DEPARTMENT 

appoints  the  other  enij^loyees  in  the  heaUh  department? 
Are  they  under  civil  service  regulations?  What  quali- 
fications are  required  of  them? 


The  Sanitary  Code  and  the  Activities  of  the  Health 

Department 

Reporting  and  Quarantine.  —  What  diseases  are  report- 
able? What  diseases  are  quarantinable?  What  is  tho. 
period  of  quarantine  for  each  disease?  When  are  different 
cases  of  disease  released  from  quarantine?  Are  laboratory 
tests  ever  made  to  determine  whether  cases  should  be 
released  from  quarantine?  If  so,  enumerate  these  dis- 
eases, and  state  what  tests  are  made,  and  under  what 
conditions  the  patient  is  released. 

Contagious  Disease  Hospital.  —  Is  there  a  contagious 
disease  hospital?  What  quarantinable  diseases  are  treated 
there  ?  A  discussion  of  this  hospital  should  be  included  in 
the  chapter  on  hospital  facilities. 

Terminal  Disinfection.  —  Is  terminal  disinfection  prac- 
tised? For  what  diseases?  What  method  of  disinfection 
is  employed?  By  whom  is  the  work  of  disinfection  per- 
formed? Are  precautions  taken  to  seal  the  cracks  and 
openings  of  each  room,  before  the  disinfection  is  begun? 
Are  the  bed  linen  and  other  things  used  by  the  sick  disin- 
fected after  the  case  has  been  terminated?  If  so,  what 
methods    of    disinfection    are    employed    for    the    various 

objects? 

Regulation  of  Midwives.  —  Are  midwives  licensed?  If 
not,  are  they  supervised?  W^hat  precautions  are  taken 
to  prevent  ophthalmia  neonatorum?  Are  physicians  and 
midwives  required  to  use  silver  nitrate  solution  in  the 
eyes  of  every  new-born  child? 

Health  Index.  —  Is  a  health  index,  showing  the  normal 
prevalence  of  each  disease,  kept  by  the  heg^Uh  authorities? 


SCHOOL  CHILDREN  AFFECTED  229 

How  many  years  are  covered  oy  tne  records  on  which  this 
index  is  based?  Is  it  in  the  hands  of  a  trained  epidemiol- 
ogist or  some  other  employee  who  is  adequately  trained? 
What  is  the  endemic  index  for  each  disease?  How  does  it 
compare  with  the  endemic  indices  of  other  cities?  If  the 
endemic  index  for  any  disease  is  too  high,  this  fact  should 
be  noted  in  the  final  report. 

Public  Health  Nurses.  —  How  many  public  health  nurses 
are  employed  to  visit  need}^  cases  of  communicable  dis- 
ease? How  many  visits  does  each  make  in  a  given  period 
of  time  ?  What  is  the  nature  of  the  work  performed  during 
these  visits? 

Cases  of  Communicable  Disease.  —  The  surveyor  should 
obtain  from  the  health  officer  the  statistics  of  the  various 
communicable  diseases,  for  a  period  of  at  least  five  years. 
These  figures  should  be  studied  from  the  standpoint  of 
prevalence,  and,  if  the  circumstances  warrant,  from  the 
standpoint  of  age  and  sex  distribution.  They  should  also 
be  studied  in  relation  to  the  deaths  from  each  disease,  in 
order  to  ascertain  whether  all  the  cases  of  disease  are 
being  reported.  If  the  community  is  not  in  the  registra- 
tion area,  the  figures  may  be  compared  with  the  morbidity 
and  mortality  rates  of  neighboring  communities  which 
are  of  approximately  the  same  size  and  are  in  the  registra- 
tion area. 

Reporting  of  Births,  Deaths  and  Communicable  Dis- 
eases. —  The  surveyor  should  obtain,  from  the  health 
officer  or  the  registrar  of  vital  statistics,  all  available  in- 
formation concerning  the  reporting  of  births,  deaths  and 
communicable  diseases. 

School  Children  Affected  with  Communicable  Diseases. 
—  Does  the  school  department  report  the.  cases  of  com- 
municable disease  that  occur  among  the  pupils?  If  so, 
how  soon  after  the  child  is  excluded  is  the  report  made? 
For  what  diseases  must  the  child  be  excluded  from  school? 


230  ACTIVITIES  OF  HEALTH  DEPARTMENT 

When  is  the  child  permitted  to  resume  its  school  activities? 
Must  the  child  have  a  certificate  of  health  obtained  from 
the  health  department  before  being  readmitted  to  school? 
If  so,  under  what  conditions  is  this  certificate  granted? 
Is  any  effort  made  to  determine  whether  other  children  in 
the  same  class  have  been  infected  by  the  sick  child?  If 
so,  what  steps  are  taken  ?  Are  similar  investigations  carried 
on  among  the  playmates  of  the  sick  child,  other  than  his 
or  her  schoolmates?  If  a  public  health  nurse  is  employed 
in  the  schools,  does  she  visit  each  sick  child  who  is  excluded 
from  school  ?  If  so,  how  often  is  each  child  visited  ?  What 
does  the  nurse  do  on  each  of  these  visits? 

Sanitary  Handling  of  Foods. , —  Has  the  city  any  ordi- 
nances regulating  the  sanitary  control  of  foods  in  food- 
stores,  ice-cream  parlors,  hotels  and  restaurants?  If  so, 
a  copy  of  these  regulations  should  be  obtained  and  care- 
fully studied.  A  critical  review  of  these  ordinances  should 
be  included  in  the  chapters  covering  the  inspection  of 
food-stores  and  restaurants.  A  more  thorough  considera* 
tion  of  the  requirements  necessary  for  handling  food  satis- 
factorily will  ])e  found  in  the  chapters  dealing  more  specifi- 
cally with  that  subject. 

Medical  Examination  of  Food-Handlers.  —  Are  food- 
handlers  required  to  undergo  a  medical  examination  before 
being  permitted  to  handle  foods?  If  so,  how  often  must 
thej^  be  examined?  Who  conducts  the  examination? 
Does  the  examination  also  include  a  laboratory  examina- 
tion of  blood,  feces,  sputum  and  throat  swabs?  Is  any 
charge  made  for  this  examination?  If  so,  how  much? 
Are  certificates  of  health  issued  to  those  who  successfully 
pass  the  examination?  If  the  answers  to  these  questions 
do  not  describe  the  method  of  examination  employed,  the 
method  which  is  actually  in  use  should  be  described. 

Prohibiting  Spitting.  —  Does  the  sanitary  code  contain 
an   ordinance   prohibiting  spitting?     What   measures  are 


INSPECTION  OF   HOUSES   AND  LODGING   HOUSES      231 

taken  to  enforce  this  ordinance?  Have  any  arrests  ever 
been  made?  If  so,  how  many,  and  when  did  they  occur? 
What  does  the  health  department  do  to  instruct  the  people 
in  the  dangers  arising  from  this  undesirable  habit  ? 

Inspection  of  Houses  and  Lodging  Houses.  —  Does  the 
city  have  an  ordinance  regulating  the  sanitary  control  of 
housing  conditions  and  lodging  houses  ?  If  so,  the  surveyor 
should  procure  a  copy  and  study  itcritically,  in  order  to  com- 
ment on  it  either  in  this  chapter  or  in  the  chapter  on  housing. 

How  many  inspections  are  made  per  year?  Are  all 
parts  of  the  city  included  in  these  inspections,  or  only 
the  poorer  sections?  Are  inspections  made  as  a  matter  of 
routine,  or  only  when  nuisances  are  reported?  What 
points  are  given  particular  attention  in  these  inspections? 
Are  score-cards  or  form-cards  used?  If  so,  obtain  a  copy 
of  each  and  criticize  it  in  the  final  report. 

Do  the  inspectors  consider,  in  their  housing  inspections, 
such  factors  as  overcrowding,  unclean  bed-linen  and 
mattresses,  the  presence  or  absence  of  a  pure  and  ample 
water-supply,  the  presence  or  absence  of  sewers  or  sani- 
tary privies,  the  presence  of  nuisances  due  to  the  unsatis- 
factory disposal  of  garbage,  manure,  and  tin  cans,  the 
presence  of  mosquito-breeding  places  like  pools  of  water 
or  rain-barrels,  or  any  other  container  in  which  water  is 
present  for  approximately  two  weeks?  What  steps  are 
taken  to  overcome  the  evils  brought  to  light  during  the 
inspections?  Is  there  an  available  record  which  shows 
the  conditions  that  have  been  remedied?  If  there  is  one, 
obtain  a  copy  of  it,  and  include  it  in  the  final  report. 

If  the  sanitary  code  governs  the  regulation  of  theatres, 
public  buildings  or  public  conveyances,  the  surveyor  should 
examine  these  critically  and  describe  exactly  what  has  been 
done  to  put  the  regulations  into  practice. 


232  ACTIVITIES  OF  HEALTH  DEPARTMENT 

Inspection  of  Railroad  and  Comfort  Stations 

Frequency  of  Inspections.  —  Are  the  railroad  stations 
regularly  inspected  ])y  employees  of  the  health  depart- 
ment? If  so,  how  often  are  these  inspections  made? 
How  many  railroad  stations  are  there  in  the  city? 

Toilet  Facilities.  —  Are  the  toilet  facilities  for  both 
sexes  adequate  and  satisfactory  in  each  case?  Are  the 
toilet-rooms  clean,  airy,  light  and  well  ventilated?  Are 
the  toilet  facilities  private?  Are  the  necessary  accessories 
furnished  ? 

Washing  Facilities.  —  Are  washing  facilities  available 
in  the  toilet-rooms?  Are  soap  and  individual  towels 
provided?     Is  hot  water  provided? 

Screens  and  Urinals.  —  Are  the  toilet-rooms  screened  ? 
Are  urinals  provided  and  kept  in  good  order? 

Comfort  Stations.  —  The  above  questions  also  apply  to 
the  public  comfort  stations.  In  addition,  the  surveyor 
should  ascertain  the  number  of  public  comfort  stations 
and  their  distribution. 

Drinking  Facilities  —  Bubbling  Fountains.  —  Are  drink- 
ing facilities  provided  at  the  railroad  stations?  Is  the 
water  distributed  through  bubbling  fountains,  or  through 
barrels,  coolers  or  other  containers?  Is  the  water  cooled 
during  the  summer?  If  bubbling  fountains  are  employed, 
are  they  of  that  type  which  prevents  the  fouling  of  the 
bubbler  with  the  mouth  washings? 

Individual  Cups.  —  If  bubbling  fountains  are  not  em- 
ployed, are  individual  cups  provided?  If  not,  is  the  com- 
mon drinking-cup  employed? 

Source  and  Safety  of  Water-Supply.  —  What  is  the 
source  of  the  drinking-water  used?     Is  it  considered  safe? 

Benches.  —  Are  benches  provided  in  the  station  ?  Are 
they  adequate  in  number  to  accommodate  the  patrons 
most  of  the  time? 


PUBLIC   HEALTH  EDUCATION  233 

Rubbish  Barrels.  —  Are  barrels  for  receiving  rubbish 
provided,  and  are  they  conveniently  placed? 

General  CleanUness.  —  Is  the  station  clean  and  well 
kept?     Is  it  airy  and  comfortable? 

Segregation.  —  Are  the  people  segregated  in  the  stations, 
or  in  the  cars  or  other  conveyances?  If  so,  what  is  the 
basis  of  segregation?  Where  the  people  are  segregated, 
an  inspection  should  be  made  of  the  quarters  which  are 
provided  for  each  element. 

Other  Stations.  —  Other  stations  used  in  connection  with 
transportation,  such  as  ferry-boat  and  steamship  stations, 
should  also  be  inspected  in  a  manner  similar  to  that  out- 
lined above. 

Control  of  the   Milk-Supply 

This  subject  has  been  treated  separately  in  a  special  chap- 
ter. The  rea.der  is  referred  to  that  chapter  for  the  infor- 
mation required  on  this  subject. 


The  Control  of  Tuberculosis 

This  subject  will  be  treated  in  the  chapter  on  tuberculosis, 
where  the  information  required  under  this  head  will  be  out- 
lined. 

School  Hygiene  and  Sanitation 

These  subjects  have  been  treated  in  separate  chapters, 
to  which  the  reader  is  referred. 


Public  Health  Education 

Education  through  the  Eye.  —  Does  the  health  depart- 
ment attempt  to  educate  the  public  in  healthy  living? 
What  methods  are  used?  Are  lectures  on  various  public 
health    topics    given?     Are    stereopticon    shdes    used    for 


234  ACTIVITIES   OF   HEALTH   DEPARTMENT 

purposes  of  public  health  education?  Are  motion-pictures 
employed?  Are  exhibits  used?  Does  the  health  depart- 
ment issue  circulars,  posters,  advertisements,  bulletins, 
reports,  or  any  other  form  of  printed  matter  which  may 
aid  in  increasing  the  people's  knowledge  in  regard  to 
health  ? 

Education  through  Public  Health  Nurses.  —  Are  public 
health  nurses  employed?  If  so,  how  many?  What 
branches  of  public  health  work  do  they  cover?  How 
many  tuberculosis  nurses  are  employed?  How  many 
school  nurses?  How  many  communicable-disease  nurses? 
How  many  infant-welfare  nurses?  Is  there  any  other 
kind  of  public  health  nurse,  such  as  a  venereal-disease 
nurse,  or  a  nutrition-clinic  nurse?  If  so,  enumerate  them 
and  describe  the  work  they  do. 

Clinics  and  Health  Centers.  —  Does  the  health  depart- 
ment maintain  any  tuberculosis  clinics?  Any  infant- 
welfare  clinics?  Any  venereal-disease  clinics?  Any  nutri- 
tion clinics?  Any  other  clinics  that  have  not  been  enu- 
merated? Does  the  health  department  operate  a  health 
center?  If  so,  the  work  of  the  center  should  be  studied 
and  described  very  carefully.  The  work  of  each  clinic 
should  also  be  carefully  studied  and  described. 

Other  Means  of  Public  Health  Education.  —  Is  there 
any  activity,  other  than  those  mentioned,  which  promotes 
the  people's  knowledge  of  healthy  living?  Each  phase  of 
public  health  education  which  the  health  department 
carries  on  should  be  studied  from  the  points  of  view  of 
quality  and  extent,  and  recorded  in  the  report. 

Records  and  Reports 

Are  regular  form-cards  used  for  keeping  the  department 
records  and  vital  statistics?  If  so,  obtain  a  copy  of  each 
form,  and  criticize,  if  criticism  is  necessary.     Are  the  rec- 


LABORATORY   FACILITIES   AND   DIAGNOSES       235 

ords  kept  systematically  and  are  they  up-to-date?  How 
often  are  they  examined  and  analyzed?  Are  daily  spot- 
maps  or  other  devices  employed  to  show  the  prevalence  of 
disease  ?  Does  the  health  department  issue  an  annual  re- 
port? Does  it  issue  any  other  reports  or  bulletins?  Ex- 
amine each  report  carefully  and  criticize  its  content  and 
form.  Estimate  its  value  in  disseminating  knowledge  of 
public  health,  in  describing  the  work  of  the  department, 
and  in  serving  as  a  permanent  record  of  the  work  and  sta- 
tistics of  the  department. 

Laboratory  Facilities  and  Diagnoses 

Does  the  health  department  maintain  a  public  health 
laboratory?  If  so,  where  is  it  located?  When  was  it 
established?  Is  the  equipment  adequate  and  satisfactory? 
Are  the  members  of  the  technical  staff  properly  trained  for 

the  work? 

Water-Analyses.  —  What  water-analyses  are  performed  ? 
Are  chemical  analyses  of  water  made?  Are  bacteriological 
analyses  of  water  made?  What  waters  are  examined? 
How  often  is  each  water  examined?  Obtain  a  record  of 
past  results  for  consideration  in  the  final  report. 

Milk-Analyses.  —  Are  milk-analyses  made  ?  What  tests 
are  performed  on  the  milk?  What  milks  are  examined? 
How  often  is  each  milk  examined?  Obtain  a  record  of 
past  results  for  consideration  in  the  final  report. 

Laboratory  Diagnostic  Tests.  —  Are  final  laboratory 
diagnoses  of  disease  performed  ?  What  diagnoses  are 
made?  How  many  specimens  of  each  type  are  examined 
in  a  week?  Obtain  a  record  of  work  done  for  a  whole 
year  or  several  years,  if  possible,  and  include  in  the  final 
report.  If  certain  tests  are  made  only  occasionally  or 
only  on  definite  days,  ascertain  exactly  when  the  tests  are 
performed  and  the  frequency  of  each. 


236  ACTIVITIES  OF   HEALTH   DEPARTMENT 

Vaccines,    Sera,   Antitoxins 

Does  the  health  officer  keep  on  hand  a  supply  of  vaccines, 
sera  and  antitoxins?  If  so,  what  immunizing  agents  are 
kept  on  hand?  Are  they  distributed  free?  If  not,  what 
is  the  charge?  Does  the  health  department  administer 
these  immunizing  agents  at  any  time  ?  If  such  is  the  case, 
under  what  circumstances? 

•     Is  everybody  required  to  be  vaccinated  for  smallpox? 
Is  the  use  of  any  other  immunizing  agent  compulsory? 

What  quantity  of  each  immunizing  substance  is  used 
during  the  year?  Who  manufactures  the  products  that 
are  used? 

Clinics  and  Contagious  Disease  Hospital 

Enumerate  all  the  clinics  which  the  health  department 
maintains  or  with  which  it  is  associated.  Each  clinic  should 
be  visited  and  the  work  of  each  carefully  studied.  The  or- 
ganization of  each  clinic  should  be  graphically  shown,  if 
possible;  and  the  results  accomplished  should  also  be  indi- 
cated. The  method  of  receiving  patients,  of  recording 
their  histories  and  other  relevant  data,  of  following  up  each 
case,  of  securing  the  assistance  and  cooperation  of  other 
civic  and  private  agencies  which  are  frequently  necessary  to 
overcome  financial  or  other  difficulties  —  all  these  phases 
of  the  work  of  the  clinic  should  be  studied  and  described, 
and  suggestions  made  for  possible  improvement. 

The  surveyor  should  also  determine  whether  a  contagious 
disease  hospital  is  in  existence,  and  how  effective  it  is  in 
combating  disease.  The  information  which  should  be 
obtained  regarding  the  contagious  disease  hospital  is  out- 
lined in  the  chapter  dealing  with  hospital  facilities. 


APPROPRIATIONS  237 

Appropriations 

The  question  of  appropriations  and  expenditures  for  health 
work  is  discussed  in  detail  in  the  chapter  on  the  analysis 
of  the  city  budget.  It  is  desirable  not  only  to  refer  to  this 
work  in  connection  with  the  study  of  the  health  department, 
but  to  include  an  outline  of  the  health  department's  ex- 
penses or  appropriations  for  the  past  few  years,  and  another 
outline  showing,  in  skeleton  form,  the  plan  of  reorganization 
of  the  health  department,  if  such  a  reorganization  h  found 
to  be  desirable.  In  the  plan  of  reorganization,  the  salary 
for  each  employee  and  the  money  necessary  to  maintain 
the  activities  of  the  department  should  be  suggeoted. 

The  surveyor  should  be  particularly  careful  to  dissociate 
all  work  of  the  health  department  which  does  not  bear  any 
relation  to  the  preservation  of  health  or  the  prevention  of 
disease  from  that  which  has  an  intimate  relationship  to  the 
public  health.  Thus,  if  the  health  officer  is  also  the  super- 
intendent of  refuse  collection  and  disposal,  the  money 
appropriated  for  this  purpose  must  not  be  confused  with 
the  money  available  for  employing  public  health  nurses, 
for  a  bacteriologist,  a  vital  statistician  or  a  milk  inspector, 
or  for  any  of  the  numerous  and  varied  functions  which  the 
health  department  is  called  upon  to  perform. 

It  is  also  advisable  to  point  out  the  relative  per  capita 
appropriations  for  the  various  municipal  activities,  and 
also  to  compare  the  per  capita  appropriation  for  health 
work  in  the  city  which  is  being  studied,  with  similar  appro- 
priations for  other  cities  having  approximately  the  same 
population.  If  these  other  cities  are  located  in  the  same 
section  of  the  country,  the  figures  quoted  will  have  added 
significance. 


238 


ACTIVITIES  OF  HEALTH  DEPARTMENT 


Cooperation   with   Other   Agencies 

In  every  communit}^  there  are  many  welfare  agencies 
which  are  supported  by  private  means.  They  are  fre- 
quently active  and  keenly  interested  in  promoting  the  pub- 
lic health,  and  very  often  can  do  things  which  a  municipal 
department  of  health  either  could  not  do  or  would  find  great 
difficulty  in  accomplishing.     These  agencies  frequently  in- 


FiG.  83.  A  private  health  and  welfare  agency  which  is  doing  good 
work  for  the  care  of  the  young,  and  especially  in  those  cases  where  the 
mother  is  gainfully  employed  during  the  day. 

elude  health  experiment  stations,  where  new  ideas  in  health 
work  can  be  tried  out  on  a  larger  or  smaller  scale,  before 
thsy  are  taken  over  by  the  community.  They  arc  often 
active  agents  in  disseminating  health  information.  They 
may  employ  public  health  nurses,  maintain  clinics  or  day 
camps,  or  dispense  financial  or  material  aid  whenever 
necessary,  and  in  many  other  ways  they  may  be  of  great 
importance  and  value  in  promoting  the  public  health  and 
welfare  of  the  community. 


TABLES,   CHARTS,   FORMS,   PHOTOGRAPHS         239 

Among  the  organizations  which  will  be  found  in  most 
communities,  are  a  tuberculosis  association,  a  visiting 
nurses'  association,  a  group  of  associated  charities  or 
various  individual  charities,  certain  private  clinics  and 
welfare  stations,  and  a  chapter  of  the  Red  Cross.  The 
best  work  will  be  done  where  the  health  officer  is  able  to 
coordinate  the  efforts  of  all  these  agencies  with  those  of 
his  own  department.  In  any  case,  the  surveyor  should 
study  the  activities  of  these  agencies  and  the  relationship 
and  cooperation  between  them  and  the  health  department; 
and  the  results  of  this  study  should  be  incorporated  in  the 
final  report. 

Cooperation  of  the  Police 

In  some  instances,  there  is  close  cooperation  between  the 
police  department  and  the  health  department,  with  a  view 
to  the  abatement  of  nuisances.  Such  a  relationship  is  very 
desirable,  as  the  policeman  is  usually  more  intimately  ac- 
quainted with  the  condition  of  the  district  he  patrols  than 
any  other  public  officer.  In  some  cities,  the  police  are  re- 
quired to  observe  the  existence  of  nuisances  and  to  require 
the  owner  of  the  premises  or  the  individual  responsible  for 
the  nuisance  to  remove  or  abate  it.  Such  cooperation  on 
the  part  of  the  police  department  relieves  the  officials  of 
the  health  department  from  the  need  for  discovering  and 
following  up  nuisances.  In  that  way,  they  have  more  time 
to  pursue  other  activities  which  affect  the  health  of  the 
people  more  directly.  If  such  cooperation  between  the 
health  department  and  the  police  department  exists,  the 
surveyor  should  study  the  situation  and  include  the  facts 
in  his  report. 

Tables,   Charts,   Forms,   Photographs 

The  following  outline  will  help  to  recall  many  of  the  im- 
portant points  to  be  considered  in  the  report.     In  addi- 


240  ACTIVITIES  OF  HEALTH  DEPARTMENT 

tion  the  surveyor  should  add  any  tables,  charts  or  photo- 
graphs which  may  be  of  value  in  this  connection.  There 
should  be  at  least  two  tables  showing  the  present  organiza- 
tion and  distribution  of  the  budget,  and  the  organization 
and  distribution  proposed  by  the  surveyor.  A  chart  show- 
ing the  proposed  organization,  and  the  personnel  and 
relation  of  the  various  divisions,  should  also  be  included. 


OUTLINE  OF  CHAPTER  ON  ORGANIZATION  AND  ACTIVITIES 
OF   THE  HEALTH   DEPARTMENT 

1.  Organization  and  personnel  of  board  of  health.  How  appointed? 
Term  of  office.     Powers.     Duties.     Frequency  of  meetings. 

2.  Organization  and  personnel  of  health  department.  Educaiional 
and  professional  requirements  of  health  officer.  Training  and  pre- 
vious experience  of  inspectors.  Term  of  office  for  health  officer  and 
for  inspectors.     By  whom  are  inspectors  appointed?     Remuneration. 

3.  Discussion  of  sanitary  code. 

a.  Ordinances  pertaining  to  the  reporting,  isolation  and  exclu- 

sion   of    school    children    affected    with    communicable 
diseases. 

b.  Diseases    reportable.     Quarantinable  diseases.     Period    of 

quarantine.     Release  from  quarantine.     Terminal  disin- 
fection. 

c.  Sanitary   handling   of   foods.     Regulations   regarding   pro- 

tection  from   dust   and   flies.     Medical   examination   of 
food-handlers. 

d.  Ordinance  prohibiting  spitting. 

e.  Inspection  and  regulation  of  lodging  houses. 

/.  Housing  inspections,  including  inspections  for  garbage  nuis- 
ances, manure  on  jjremises, .  tin  cans,  pools,  rain-water 
barrels  and  other  mosquito-breeding  places. 

g.   Regulation  and  control  of  the  milk-supply. 

h.   Machinery  for  dealing  Nvith  tuberculosis. 

i.  Regulations  regarding  sanitation  of  theatres,  public  build- 
ings, schools,  factories  or  public  conveyances. 

j.  Health  education  through  the  visiting  nurse,  various  wel- 
fare activities,  printed  matter,  the  spoken  word,  stere- 
opticon,  moving  pictures,  exhibits. 


OUTLINE  OF  CHAPTER  241 

4.  a.  Discussion  of  most  of  these  matters  from  the  point  of  view  of 
activities  of  the  health  department. 

h.  Keeping  of  records. 

c.  Laboratory  facihties  and  diagnoses. 

d.  Analysis  of  reports,  monthly,  annual  or  any  other  kind, 

showing  work  done. 

6.    OflBce  and  laboratory  accommodations. 

/.  Per  capita  expenditures  for  health  work  and  comparison 
with  other  cities  of  same  size  and  similar  location.  Ap- 
propriation required. 

g.   Milk-stations.     Infant  welfare  work. 

h.  Clinics  and  health  centers.  Infant  welfare,  prenatal,  tuber- 
culosis, venereal  disease,  nutrition,  dental,  etc. 

i.    Hospitals,  including  the  care  of  contagious  diseases. 

j.   Use  and  distribution  of  sera,  vaccines,  antitoxins,  etc. 

k.  Welfare  agencies,  including  unofficial  public  health  agencies. 

6.   Recommendations  and  criticisms. 

a.  Outhne  model  health  organization  and  approximate  cost. 

6.  In  a  general  way,  what  should  be  the  functions  and  activi- 
ties of  a  health  department? 

c.  Pohce  to  aid  in  cleaning  up  dumps,  back-yards,  exposed 
garbage,  etc. 

6.  Charts  and  diagrams  showing   (4/)  graphically.     Also  photo- 
graphs. 

7.  Summary. 

8.  Recommendations. 


CHAPTER   XIV 
HOSPITAL   FACILITIES 

Adequate  Hospital  Facilities  are  Essential  to  the  Health 
of  the  Community.  —  In  order  to  promote  the  health  and 
welfare  of  the  people  in  a  truly  effective  manner,  the  public 
health  campaign  must  be  directed  not  only  toward  the 
prevention  of  disease,  but  also  toward  the  care  and  ulti- 
mate cure  of  those  who  are  actually  ill.  The  proper  treat- 
ment of  communicable  diseases  not  only  aids  those  who 
are  already  affected,  but  also  prevents  the  spread  of  the 
infection,  and  may  therefore  be  considered  a  preventive 
as  well  as  a  curative  measure. 

All  cases  of  disease,  whether  communicable  or  other- 
wise, are  treated  in  hospitals.  Sometimes  the  home  is 
temporarily  transformed  into  a  hospital  when  a  member 
of  the  family  becomes  ill.  More  often,  nowadays,  the 
patient  goes  to  the  institution  whose  primary  purpose  is  to 
care  for  and  cure  the  sick.  Such  institutions  are  called 
hospitals. 

The  Modern  Hospital  is  a  Powerful  Force  in  the  Public 
Health  Campaign.  —  Until  recently,  the  hospitals  were 
interested  almost  entirely  in  the  care  of  the  sick  and  in  the 
education  of  nurses.  Even  if  this  were  still  the  case,  we 
should  be  justified  in  including  a  study  of  the  hospital 
facilities  in  a  public  health  survey  of  a  community.  More 
recently,  however,  the  hospital  has  begun  to  widen  its 
field  of  activity,  and  has  become,  in  many  cases,  an  im- 
portant agent  in  the  public  health  campaign. 

The  new  hospital  activities  include  the  development  of 
dispensaries  and  clinics  of  all  sorts   including  those  for  the 

242 


MODERN   HOSPITALS  A  POWERFUL  FORCE       243 

treatment  of  eye,  ear,  nose  and  throat  defects,  tuberculosis 
clinics,  industrial,  nutrition  and  orthopedic  clinics,  and 
clinics  for  venereal  diseases  and  for  organic  ailments.  Some 
hospitals  are  giving  courses  in  public  health  nursing  and 
are  attempting  to  spread  the  gospel  of  hygiene  and  sani- 
tation through  various  educational  methods.  In  addition, 
most  hospitals  now  have  excellent  laboratory  facilities  for 
the  diagnosis  of  disease,  so  that  each  hospital  is  also,  in  a 
restricted  sense,  a  pubUc  health  laboratory. 


Fig.  84.  View  of  the  newly  constructed  University  Hospital  in 
Oklahoma  City,  which  is  provided  with  176  beds  and  excellent  surgical, 
medical  and  X-ray  facihties.  Special  research  laboratories  and  obstetri- 
cal and  social  service  departments  are  also  provided. 

Joseph  J.  Weber,*  Managing  Editor  of  Modern  Hospital, 
gives  the  following  definition  of  a  modern  hospital.  ''A 
hospital  is  an  institution  whose  objects  are  the  care  and 
treatment  of  the  physically  and  mentally  ill  and  injured, 
the  education  of  patients  in  hygiene,  both  personal  and 
public,  the  clinical  training  of  doctors,  nurses  and  hospital 
social  service  workers,  the  advancement  of  medical  science, 
and   the  prevention   of  disease."     For   all   these   reasons, 

*  The  Role  of  the  Hospital  in  the  Public  Health  Campaign.  Volume 
XV,  Number  I,  July,  1920,  page  15. 


244 


HOSPITAL  FACILITIES 


therefore,  the  hospital  has  a  place  in  the  public  health 
survey. 

Modern  Contagious  Disease  Hospitals  should  be  Avail- 
able. —  The  general  hospital,  in  which  surgical,  medical 
and  obstetrical  cases  are  treated,  is  the  most  common  type 
of  institution  for  the  care  of  the  sick.  Usually,  cases  of 
typhoid  fever,  pneumonia  and  bone-tuberculosis  are  also 


Fig.  85.  A  contagious  disease  hospital,  more  commonh'  kno^\^l  as 
the  "Pest  House,"  still  in  use  in  many  places.  These  places  are  in- 
accessible and  are  not  even  provided  with  sanitary  conveniences. 
They  are  a  disgrace  to  modern  civilization  and  the  humanitarian  spirit 
of  mankind. 

treated;  but  there  are  many  communities  which  do  not 
provide  adequate  facilities  for  the  treatment  of  other 
'contagious  diseases,  such  as  pulmonary  tuberculosis, 
measles,  whooping-cough,  diphtheria,  scarlet  fever,  gonor- 
rhoea, syphilis  and  smallpox.  In  many  places,  poor, 
dilapidated,  indescribable  pest-houses  are  still  maintained 
for  the  isolation  of  cases  of  smallpox  and  other  dreaded 
diseases.  The  treatment  given  in  these  places  is  decidedly 
unsatisfactory,    and  every  community  should  be  required 


OTHER   HOSPITALS  245 

to  abandon  the  inhuman  practice  of  denying  proper  care 
to  those  suffering  from  certain  diseases. 

\  Cases  of  contagious  disease,  regardless  of  their  character, 
should  be  treated  in  modern  hospitals,  conveniently  located 
in  the  city,  and  under  the  supervision  and  care  of  trained 
physicians  and  nurses.  Obviously  it  is  absurd  for  general 
hospitals  to  treat  such  communicable  diseases  as  typhoid 
fever  and  pneumonia,  and  to  refuse  to  treat  other  com- 
municable diseases  which  are  equally  contagious.  Cities 
like  New  York  and  Boston  have  led  the  way  in  providing 
adequate  and  satisfactory  facilities  for  the  treatment  of 
cases  of  communicable  disease  right  in  the  heart  of  each 
city,  thus  demonstrating  that  the  hospital  treatment  of 
contagious  diseases  can  be  conducted  in  the  city  without 
becoming  a  menace  to  the  people.     It  is  the  duty  of  health 

,  workers  generally,  and  of  health  surveyors  particularly,  to 
educate  those  communities  which  do  not  provide  adequate 
and  satisfactory  facilities  for  the  treatment  of  contagious 
disease.  Such  communities  must  be  made  to  realize  that 
these  facilities  are  urgently  needed,  and  that  adequate  care 
of  contagious  diseases  in  hospitals  is  the  best  means 
of  curing  the  sick  and  of  preventing  the  spread  of 
infection. 

*  Hospitals  Other  than  the  General  and  the  Contagious 
Disease  Variety.  —  Besides  the  general  hospital  and  the 
contagious    disease    hospital,    there    are    the    tuberculosis 

.  hospitals  or  sanatoria.  There  are  also  hospitals  for  the 
insane;  but  these  are  usually  operated  and  controlled  by 
the  state.  The  recent  increase  in  the  number  of  tuber- 
culosis hospitals  has  been  truly  remarkable,  and  is  doubt- 
less due,  in  a  large  measure,  to  the  activity  of  the  National 
Tuberculosis  Association.  In  1904,  when  this  association 
was  organized,  there  were  but  HI  hospitals,  sanatoria, 
and  day  camps  devoted  to  the  treatment  and  care  of  the 
tuberculous.     In    1919   there    were    over   600    institutions 


246 


HOSPITAL  FACILITIES 


devoted    to   that    purpose,    and    plans    were    on    foot   for 

more. 

Private,  Endowed  and  Municipal  Hospitals.  —  Hospitals 
are  usually  private  institutions,  maintained  either  for  per- 
sonal gain  or  through  the  generosity  of  the  rich,  whose 
aim,  in  such  cases,  is  to  relieve  the  sufferings  of  humanity 
and  to  promote  our  knowledge  of  medicine  and  disease. 
Very  often,  however,  the  city  itself  maintains  a  hospital. 


I'iG.  86.  A  private  hospital,  excellently  equipped  and  weU  operated. 
These  hospitals  are  a  blessing  for  small  towns,  where  a  municipal  hos- 
pital is  not  available. 


Sometimes  this  is  a  general  hospital,  sometimes  a  con- 
tagious disease  hospital,  sometimes  a  tuberculosis  sana- 
torium, and  sometimes  a  combination  of  two  or  all  three 
of  these.  A  discussion  of  the  tuberculosis  sanatorium  will 
be  found  in  the  chapter  on  tuberculosis. 

The  Scope  of  the  Hospital  Survey.  —  In  including  the 
study  of  hospital  facilities  in  a  public  health  survey,  our 
purpose  is  not  to  consider  the  efficiency  of  operation,  but 
ratlier  to  determine  what  hospital  facilities  are  available, 


WARDS  247 

and  the  nature  of  the  work  that  is  done.  In  order  to  do 
this  the  surveyor  should  make  a  thorough  inspection  of 
each  hospital.  The  following  questions  will  suggest  the 
information  which  should  be  obtained. 


The  Hospital  Building 

What  is  the  name  of  the  hospital  ?  Where  is  it  located  ? 
Is  the  location  convenient,  quiet  and  pleasant?     • 

Of  what  material  is  the  hospital  built?  When  was  it 
built?  Is  the  building  fire-proof?  How  many  stairways 
or  inclined  passageways  are  there?  Where  are  they 
located?  How  many  elevators  are  there?  Where  are 
they  located?  What  other  precautions  are  taken  to  pro- 
tect the  patients  against  danger  from  fire?  How  many 
stories  are  there? 

Is  the  hospital  privately  or  municipally  operated  and 
controlled?  If  under  private  control,  is  any  arrangement 
made  with  the  city  for  the  care  of  city  or  charity  patients  ? 
What  arrangements  are  in  force  for  such  patients? 

Wards 

How  many  wards  are  there  in  the  hospital?  How 
many  beds  in  each  ward?  How  many  single  rooms? 
What  is  the  total  number  of  beds  available? 

Are  the  wards  large,  light,  well  ventilated  and  free  from 
overcrowding?  Are  the  single  rooms  large,  light  and  well 
ventilated  ? 

Are  satisfactory  and  convenient  toilet  facilities  provided 
for  the  wards?  For  the  single  rooms?  Are  convenient 
bathing  facilities  provided  for  the  wards?  For  the  single 
rooms  ? 

Are  the  wards  and  single  rooms  thoroughly  screened? 
Are  they  satisfactorily  provided  with  artificial  light? 


248 


HOSPITAL  FACILITIES 


Cases 

What  cases  receive  treatment  at  the  hospital?  Is  it  a 
general  hospital,  treating  medical,  obstetrical  and  surgical 
cases?  If  so,  are  cases  of  typhoid  fever,  pneumonia  and 
bone-tuberculosis  also  treated? 

Is  it  a  contagious  disease  hospital?  If  so,  what  diseases 
are  treated?  Are  diagnostic  tests  of  any  sort  made,  to 
determine  when  a  patient  should  be  released?  If  so,  what 
tests  are  made,  and  for  what  diseases?  In  cases  where 
laboratory  tests  are  not  made,  how  long  is  a  patient  kept 
before  being  discharged?  What  determines  the  fitness  for 
discharge  in  such  cases? 


Fig.  87.     Another    "Pest   House."     This   at   least   was   screened. 


The  surveyor  should  obtain  a  list  of  all  cases  under 
treatment  in  the  hospital,  and  also  some  idea  of  the  num- 
ber of  cases  of  each  disease  treated  every  year  for  several 
years  past.  He  should  ascertain  whether  the  existing 
facilities  are  equal  to  the  demands  made  upon  the  hospital. 


LABORATORY  FACILITIES  249 

Disinfection  and  Laundry 

What  methods  are  employed  for  disinfecting  bed-linen, 
eating-utensils  and  other  objects  that  come  into  contact 
with  the  patient?  If  the  patient  is  suffering  from  a  com- 
municable disease,  what  methods  are  employed  to  disinfect 
the  discharges  which  may  contain  the  infective  virus? 

Where  is  the  laundry  located?  How  does  the  linen 
reach  the  laundry?  Describe  the  methods  of  washing, 
drying,  pressing  and  sterilizing  the  linen. 

Operating -Room 

How  many  operating-rooms  are  available?  In  what 
portion  of  the  building  and  on  what  floor  is  each  located? 
Is  each  operating-room  provided  with  adequate  and  satis- 
factory natural  lighting?  Is  each  equipped  with  adequate 
and  satisfactory  artificial  lighting? 

Are  washing  facilities  for  the  surgeons  available?  Are 
these  conveniently  located?  Are  they  provided  with  hot 
water  and  liquid  soap,  or  any  soap  of  which  the  same 
portion  is  not  handled  twice?  Is  the  water  released  by 
hand,  or  by  some  part  of  the  leg?  Are  adequate  dressing- 
rooms  provided  for  the  surgeons? 

Are  there  adequate  and  satisfactory  means  for  steriliz- 
ing all  surgical  instruments  ?  Are  there  adequate  and  satis- 
factory facilities  for  sterilizing  all  dressings  and  bandages? 

Laboratory  Facilities 

Is  there  a  bacteriological  and  pathological  laboratory  on 
the  premises?  If  not,  is  one  available  for  the  use  of  phy- 
sicians? Does  the  hospital  maintain  an  X-ray  laboratory? 
If  not,  is  one  available?  If  laboratory  facilities  are  avail- 
able,   are    they   adequate   and   satisfactory?     What   tests 


250 


HOSPITAL  FACILITIES 


are    made?     Who    performs    them?     Is    the    individual 
trained  for  this  work? 


Heating  and  Ventilation 

The  surveyor  should  ascertain  the  method  employed 
for  heating  the  hospital  and  whether  or  not  a  system  of 
artificial  ventilation  is  employed.  If  artificial  ventilation 
is  employed,  the  surveyor  should  determine,  if  possible, 
whether  the  atmospheric  conditions  are  favorable  and 
satisfactory.  If  a  detailed  study  of  the  ventilating  system 
is  to  be  made,  the  surveyor  should  refer  to  the  considera- 
tion of  this  subject  in  the  chapter  on  school  sanitation. 


k-  ~ 


mm 

^^^j]^^^-i^3SBB9i 

.1 

•A 

Fig.  88.  The  municipal  hospital  at  Shawnee,  Okla.,  which  serves 
not  only  the  residents  of  the  city,  but  many  from  the  nearby  rural 
districts. 

Kitchen 

This  part  of  the  investigation  need  not  be  extensive. 
The  surveyor  should  determine  the  location  of  the  kitchen 
and  the  method  by  which  the  food  is  brought  to  the  patients, 


CLINICS  251 

giving  particular  attention  to  cleanliness  in  the  preparation 
and  handling  of  the  food,  and  in  the  kitchen  itself. 

Sun-Porches  and  Parlors 

The  surveyor  should  determine  how  many  of  these  are 
available,  and  whether  they  are  thoroughly  screened. 

Nurses'  Training  School 

• 

Is  a  training  school  for  nurses  maintained  ?  If  so,  how 
many  pupil  nurses  attend?  What  is  the  duration  of  the 
course?  Is  the  degree  R.N.  awarded  after  the  completion 
of  the  course?  What  are  the  requirements  for  admission? 
What  subjects  aie  studied?  Is  a  course  in  public  health 
nursing  also  given  ?  If  so,  the  surveyor  should  learn  what 
subjects  are  included  in  this  course,  and  who  is  responsible 
for  the  instruction,  and  should  note  the  number  of  pupils, 
and  the  duration  of  the  course. 

Clinics 

What  clinics  or  dispensaries  does  the  hospital  maintain? 
When  is  each  clinic  held?  How  many  patients  have  been 
treated  in  each  clinic  each  year,  during  the  past  few  years? 
Is  a  charge  made  for  treatment?  What  is  the  charge? 
What  is  the  nature  of  the  work  done  by  each  clinic? 

Is  a  social  service  department  maintained  for  the  hospital 
in  general,  or  for  any  of  the  cHnics?  Of  what  does  the 
work  of  the  social  service  department  consist  ?  How  many 
cases  of  each  disease  have  been  visited  or  aided  through 
the  social  service  department?  Is  there  any  available 
evidence  of  the  results  of  this  work?  If  so,  the  surveyor 
should  obtain  a  record  of  the  work  done. 

Does  the  hospital  conduct  any  propaganda  in  health 
education?     Do    the    clinics    conduct    health    educational 


252  HOSPITAL  FACILITIES 

activities  in  any  form  ?  If  so,  the  surveyor  should  acquaint 
himself  with  the  character  and  extent  of  the  educational 
work  done. 

The  following  outline  may  be  of  service  to  the  surveyor 
in  writing  his  report. 

OUTLINE   OF   CHAPTER   ON   HOSPITAL   FACILITIES 

1.  General  remarks  on  the  value  of  hospitals  in  combating  disease 
and  promoting  the  public  health. 

2.  The  hospital  buildings. 

Number;  desirability  of  location;  protection  against  fire;  height; 
wards;  beds;  private  rooms;  sanitary  conditions  in  wards  and  private 
rooms;  screens;  municipally  or  privately  owned  and  operated;  heat- 
ing; ventilation;  sun-parlors  and  porches;  kitchens;  water  facilities; 
toilet  facilities. 

3.  Cases  treated. 

Nature  of  cases  treated;  provision  for  cases  of  communicable  dis- 
ease; conditions  under  which  cases  of  communicable  disease  are  re- 
leased; number  of  patients  receiving  treatment;  overcrowding;  meth- 
ods of  disinfection  and  sterilization  employed. 

4.  0[)erating  rooms. 

Number;  location;  sanitary  conditions  and  appointments;  adequate 
light;   sterilization  of  instruments  and  dressings. 

5.  Laboratory  facilities. 

Facilities  for  bacteriological  and  pathological  diagnoses;  X-ray 
facilities. 

6.  Nurses'  training  school. 

Number  of  pupils;  length  of  course;  degree;  requirements  for 
admission;    subjects  studied;   course  in  public  health  nursing. 

7.  Clinics. 

Number;  kind;  number  of  patients  treated  at  each;  charges; 
work  of  each  clinic;  follow-up  work  through  social  service  depart- 
ment; results  obtained;  public  health  educational  activities  through 
hospitals  and  clinics. 

8.  Summary. 

9.  Recommendations. 


CHAPTER   XV 
TUBERCULOSIS 

Tuberculosis —**  The  Great  White  Plague.'*  —  Tuber- 
culosis is  probably  the  most  important  disease  of  the 
human  race.  It  causes  about  10  per  cent  of  all  the  deaths 
which  occur  in  the  United  States,  while  in  other  countries 
the  rate  is  frequently  higher.  It  is  a  disease  which  removes 
people  in  the  prime  of  life,  at  a  time  when  they  are  most 
needed  by  their  families,  and  when  they  should  be  able  to 
render  the  greatest  service  to  the  state. 

Tuberculosis  is  insidious  in  its  onset,  overcoming  the 
individual  gradually,  and  is,  therefore,  particularly  diffi- 
cult to  combat.  A  disease  like  plague,  cholera,  typhoid 
fever  or  smallpox,  which  is  comparatively  rapid  in  its 
onset  and  possibly  fatal  culmination,  inspires  such  fear  in 
the*  affected  individual,  that  he  takes  all  the  precautions 
necessary  for  a  speedy  recovery.  The  duration  of  tuber- 
culosis is  comparatively  long;  and  frequently  the  affected 
individual  does  not  suspect  the  presence  of  the  disease 
until  it  is  almost  too  late.  A  slight,  gradual  loss  of  weight, 
a  slowly  increasing  cough,  and  a  slightly  abnormal  tempera- 
ture at  different  intervals  during  the  day  are  symptoms 
which  pass  unnoticed,  or  are  not  regarded  as  being  serious. 

It  is  only  human  to  disregard  such  minor  ailments,  for 
most  people  must  continue  to  pursue  their  normal  occu- 
pations, in  order  to  support  themselves  and  their  families. 
Only  the  well-to-do  can  afford  to  notice  these  early  symp- 
toms and  to  take  the  precautions  necessary  to  build  up 
the  vital  resistance  of  the  body  against  the  attacks  of  the 
destructive  organism.     To  do  this,  the  patient  must  have 

253 


254 


TUBERCULOSIS 


absolute  rest  and  freedom  from  worry,  for  a  period  of  six 
months  or  a  year,  under  satisfactory  and  congenial  sur- 
roundings. The  average  wage-earner  is  unable,  in  the 
first  place,  to  afford  such  a  long  vacation,  and  frequently 
cannot  bear  the  separation  from  his  family  and  friends. 
Sometimes  the  necessary  funds  for  proper  treatment  could 
be  found;  but  the  individual  lacks  intelligence  or  sufficient 
knowledge  of  the  disease,  to  realize  its  seriousness,  and  to 
submit  to  the  trying  treatment  which  is  necessary  in  order 
to  arrest  its  progress. 


Fig.  89.     A  young  tuberculous  mother  in  the  advanced  stages  of  the 
disease,  being- cared  for  by  a  nurse  of  a  local  tuberculosis  association. 


Tuberculosis  is  a  Broad  Public  Health  Problem.  —  It  is 
unfortunate  that  tuberculosis  is  a  disease  which  is  inti- 
mately associated  with  almost  every  phase  of  community 
life.  It  has  a  distinct  relation  to  industry,  to  the  milk- 
supply,  the  water-supply  and  other  foods.  It  is  also  asso- 
ciated with  housing  conditions,  with  the  absence  of  ade- 
quate and  satisfactory  sewerage,  with  poverty,  and  with 
almost  every  phase  of  the  socio-economic  order.     All  the 


METHODS  OF  SPREADING  255 

conditions  which  tend  to  diminish  the  vital  resistance  of 
the  people  also  tend  to  increase  the  prevalence  of  tuber- 
culosis. Dusty  trades,  low  wages,  long  hours  of  employ- 
ment, poor  ventilation  in  industrial  plants,  in  schools  and 
in  homes,  milk  obtained  from  tuberculous  cattle,  the  lack 
of  a  safe,  adequate,  and  convenient  water-supply,  the  lack 
of  proper  and  adequate  sewerage  facilities,  the  lack  of 
proper  control  over  food-handlers  and  food-distributors, 
the  lack  of  clean,  au-y,  sunny  homes,  the  presence  of  over- 
crowding, the  lack  of  proper  care  for  those  who  are  ill,  — 
all  of  these  are  factors  in  diminishing  the  vitality  of  the 
people  and  increasing  the  prevalence  of  the  disease.  It  is 
obvious,  therefore,  that  the  problem  of  combating  tuber- 
culosis involves  the  improvement  of  all  these  conditions. 
It  is  only  by  attacking  the  disease  in  the  broadest  possible 
way,  that  real  and  lasting  progress  against  it  will  be  made. 

The  Oklahoma  Tuberculosis  Association  realized  this 
and  instituted,  in  1918,  a  general  public  health  survey  of 
the  eight  largest  cities  in  Oklahoma,  as  a  means  of  combat- 
ing tuberculosis.  Later,  this  association  established  child- 
welfare  clinics  in  many  parts  of  the  state,  for  the  purpose 
of  fighting  the  disease  by  improving  the  general  health. 
These  activities  are  distinct  from  those  which  aim  at  the 
establishment  of  tuberculosis  clinics,  tuberculosis  sanatoria, 
all-day  camps,  open-air  schools  and  the  employment  of 
tuberculosis  nurses  and  special  expert  medical  advisers  on 
tuberculosis.  More  recently  still,  an  industrial  field  secre- 
•  tary  has  been  employed  by  the  Oklahoma  Tuberculosis 
Association  for  the  purpose  of  preaching  good  hygiene  and 
sanitation  in  industry.  This  was  done  not  only  as  a 
means  of  checking  tuberculosis,  but  also  for  the  purpose 
of  interesting  employers  in  the  public  health  and  tuber- 
culosis campaigns. 

The   Methods   of   Spreadmg   Tuberculous   Infection.  — 
Tuberculosis    is    spread    primarily    through    the    infected 


256 


TUBERCULOSIS 


sputum  of  persons  suffering  with  the  disease.  This  sputum 
contains  the  tubercle  bacilh,  which  are  the  causative 
agents  of  tuberculosis.  It  is  also  spread,  especially  among 
children,  by  milk  which  has  become  infected  with  bovine 
tubercle  bacilli.  Infected  milk  is  supposed  to  be  respon- 
sible for  a  large  number  of  cases  of  tuberculosis,  especially 
the  abdominal  type  and  also  that  variety  which  affects 
the  cervical  lymph  nodes.  Pulmonary  tuberculosis  in  man 
is  rarely,  if  ever,  associated  with  the  bovine  tubercle 
bacillus. 


ViG.  90.  Another  tuberculous  mother  also  under  the  supervision 
of  a  tuberculosis  nurse,  who  often  brings  to  such  cases  the  only  cheer 
and  comfort  they  have. 


Just  how  the  human  tubercle  bacillus  is  transmitted 
from  one  person  to  another  is  a  questionable  matter. 
Doubtless  some  are  infected  by  contact  with  tuberculous 
sputum,  and  others  by  inhaling  air  which  contains  tubercle 
bacilli,  or  small  droplets  of  material  emitted  into  the  air 
with  the  coughing  of  tuberculous  individuals.  Others 
pro]ja])ly  contract  the  disease  by  ingesting  food  which  has 


THE  ANTI-TUBERCULOSIS   MOVEMENT  257 

become  infected  with  tubercle  bacilli.  Examinations  made 
on  autopsy,  and  by  the  use  of  the  von  Pirquet  reaction, 
show  that  almost  everybody  is  infected  with  tuberculosis, 
although  all  do  not  develop  the  disease  in  an  active  form. 
Most  children,  on  examination,  show  the  existence  of 
infection.  It  is  therefore  believed  by  some  that  the  infec- 
tion usually  takes  place  in  childhood,  and  that  it  remains 
quiescent  until  the  vital  resistance  of  the  body  becomes 
so  diminished  that  it  has  an  opportunity  to  develop. 

For  a  long  time,  it  was  believed  that  tuberculosis  was 
hereditary,  because  so  many  children  of  tuberculous 
parents  developed  the  disease.  The  more  modern  concep- 
tion maintains  that  tuberculosis  is  not  transmitted  at  birth 
to  the  child,  but  that  the  child  inherits  a  physique  which 
has  a  tendency  to  the  disease.  Moreover,  the  children  of 
tuberculous  parents  are  more  apt  to  develop  tuberculosis, 
because  of  their  intimate  and  constant  association  with 
those  who  are  giving  off  tubercle  bacilli.  For  this  reason, 
attempts  have  been  made  to  establish  preventoria,  where 
infants  whose  parents  are  tuberculous  could  be  cared  for 
and  reared,  away  from  the  danger  of  infection.  This  is 
similar,  in  a  measure,  to  the  Bang  system  for  preventing 
tuberculosis  in  cattle,  by  removing  the  calf  from  its  mother 
immediately  after  birth,  and  feeding  it  on  pasteurized 
milk  or  milk  free  from  tubercle  bacilli.  It  is  evident  that 
such  a  system  would  be  extremely  difficult  to  introduce 
among  human  beings,  since  very  few  mothers  would  be 
willing  to  part  with  their  babies. 

The  Anti-Tuberculosis  Movement  Developed  Rapidly. 
—  The  growth  of  the  anti-tuberculosis  movement  has  been 
phenomenal.  Doubtless  much  of  the  impetus  was  given 
to  it  by  the  splendid  work  and  outstanding  personality  of 
Dr.  Edward  Trudeau,  the  founder  of  the  first  sanatorium 
in  this  country,  and  also  the  founder  of  one  of  the  most 
important  centers  for  research  in  tuberculosis.     There  is 


258  TUBERCULOSIS 

now  a  National  Tuberculosis  Association,  with  local  asso- 
ciations in  every  state,  and  municipal  associations  in  many- 
cities.  All  of  these  organizations  have  done  splendid  work 
in  checking  the  ravages  of  tuberculosis  through  education 
in  its  various  forms,  through  the  establishment  of  tuber- 
culosis clinics,  sanatoria,  open-air  classes,  open-air  schools, 
day  camps  and  nutrition  classes,  through  the  employment 
of  tuberculosis  nurses,  who  visit  the  patients  in  their  homes 
and  keep  a  careful  record  of  the  progress  of  each  case,  and 
through  cooperation  in  the  general  public  health  campaign 
and  other  welfare  activities  in  the  community. 

Methods  of  Studying  the  Tuberculosis  Situation.  —  The 
study  of  the  tuberculosis  situation  in  a  community  may  be 
divided  into  two  parts.  First  a  thorough  study  should  be 
made  of  the  available  statistics  for  cases  of  tuberculosis 
and  for  deaths  resulting  therefrom.  Second,  the  organi- 
zation and  activities  of  any  existing  anti-tuberculosis 
agency  should  be  carefully  considered.  In  many  cases 
the  tuberculosis  activities  are  conducted  by  private  organi- 
zations, supported  by  voluntary  subscription  on  the  part 
of  the  public,  while  in  other  instances  the  work  is  conducted 
by  the  local  health  department.  The  surveyor  should 
definitely  determine  which  agency  is  conducting  the  anti- 
tuberculosis work.  If  both  the  local  health  department 
and  the  voluntary  tuberculosis  organization  are  taking 
part  in  the  campaign,  the  work  of  both  should  be  studied. 

Statistical  Study 

In  making  the  statistical  study,  sufficient  weight  should 
be  given  to  such  factors  as  the  race  and  sex  distribution 
of  the  population,  and  the  predominating  occupations. 
It  is  well  known  that  the  Irish,  the  Scandinavians,  the 
Negroes  and  the  Indians  show  high  mortality  rates  from 
tuberculosis.     It    has    also    been    established    that    dusty 


STATISTICAL   STUDY  259 

occupations,  such  as  cotton  and  woolen-mill  work,  stone- 
cutting  and  polishing,  and  work  in  the  metal  trades,  where 
large  quantities  of  metallic  dust  are  created,  cause  high 
tuberculosis  incidence  and  mortality  rates  among  the 
employees.  A  study  of  the  prevalence  of  tuberculosis 
among  these  various  trades,  and  among  the  various  races, 
may  throw  more  light  on  the  tuberculosis  problem  in  a  com- 
munity than  the  consideration  of  the  prevalence  of  tuber- 
culosis in  the  general  population.  Wherever  a  special 
tuberculosis  problem  exists,  either  because  of  industry  or 
of  race,  this  problem  should  receive  special  consideration. 

The  statistics  regarding  the  prevalence  of  tuberculosis 
and  the  number  of  deaths  which  it  causes  each  year  can  be 
obtained  from  the  records  of  the  health  department.  The 
surveyor  should  ascertain  whether  tuberculosis  is  a  report- 
able disease,  and  should  determine,  from  a  comparison  of 
the  number  of  cases  and  the  number  of  deaths  reported 
every  year,  whether  all  cases  of  tuberculosis  have  been 
reported.  It  is  generally  estimated  that  for  every  death 
from  tuberculosis  there  are  at  least  ten  active  cases  of  the 
disease.  Comparisons  should  also  be  made  between  the 
prevailing  death-rates  from  tuberculosis  in  the  city  under 
consideration  and  the  rates  for  all  the  registration  cities. 
Similar  comparisons  should  be  made  with  neighboring 
cities  in  which  the  conditions  are  similar. 

The  following  table  may  be  used  to  incorporate  the 
statistical  data  which  should  be  obtained. 


260 


TUBERCULOSIS 


TABLE  30 

CASES,  DEATHS  AND  DEATH-RATES  FROM  ALL  FORMS  OF 

TUBERCULOSIS   IN    "CITY   A,"    WITH   A   COMPARISON    OF 

DEATH-RATES   IN    OTHER   CITIES,    1911-1920 


• 

Popula- 
tion. 

Cases 
reported. 

Deaths 
reported 

Specific 
death- 
rate. 

Specific  death-rates  in 

Year. 

U.  S.  reg- 
istration 
cities. 

City 
B. 

City 
C. 

City 
D. 

1911.... 

1912.... 

1913.... 

1914... 

1915.... 

1916... 

1917... 

1918... 

1919... 

1920 . . . 

Average. 

"? 

The  statistics  in  the  above  table  should  be  discussed 
thoroughly  and  illustrated  graphically,  in  order  to  bring 
out  the  important  points. 

The  deaths  for  the  past  ten  years  should  be  studied 
according  to  age,  color  and  race  distribution,  and  occupa- 
tion. The  figures  for  the  distribution  of  deaths  according 
to  occupation  may  not  be  as  valuable  as  the  correspond- 
ing figures  for  active  cases  of  the  disease.  The  reason  for 
this  is  that  the  individual  who  has  contracted  tuberculosis 
in  one  industry  frequently  leaves  it  after  he  becomes  ill 
and  obtains  employment  in  an  industry  that  is  absolutely 
harmless.  Obviously,  it  would  be  unfair  to  charge  the 
death  from  tuberculosis  against  the  harmless  industry,  in 
which  he  may  be  employed  at  the  time  of  his  death.     In 


DEATH-RATES 


261 


spite  of  frequent  inaccuracies  of  this  kind,  it  will  probably 
be  of  considerable  value  to  study  the  distribution  of  deaths 
according  to  occupations.  From  the  dispensary  records, 
or  any  other  records  that  are  available,  a  distribution  of  the 
active  cases  according  to  occupation  should  also  be  made. 
The  following  tables  indicate  how  the  deaths  from  tuber- 
culosis, according  to  race,  age  and  occupation,  should  be 
.recorded. 

TABLE  31 

DEATH-RATES    FROM    ALL    FORMS    OF    TUBERCULOSIS    IN 
"CITY  A,"   AND    OTHER   CITIES,    1911-1920,   DISTRIBUTED 

ACCORDING   TO   COLOR 


Year. 

City  A. 

City  B. 

City  C. 

W. 

B. 

W. 

B. 

W. 

B. 

1911 

^^- 

1912 

1913 

1914 

1915 

1916 

1917 

1918 

1919 

1920 

The  cities  used  for  comparison  should  have  approxi- 
mately the  same  percentage  of  negroes  as  the  city  under 
consideration,  and  other  conditions  should  be  as  nearly 
alike  as  possible.  Negroes  usually  show  a  high  mortality 
rate  from  tuberculosis.  This  fact  is  exceedingly  important, 
not  only  because  it  is  imperative  to  diminish  the  rate 
among  negroes,  but  also  because  the  negroes  mingle  inti- 
mately with  the  whites  and  are  therefore  a  constant  menace 
to  them.  The  negroes  act  as  servants,  nursemaids,  waiters 
and  laundresses,  and  in  many  other  ways  are  intimately 


262 


TUBERCULOSIS 


associated  with  the  white  people  and  their  children.  If 
white  people  are  to  be  protected  against  infection,  it  is  also 
important  to  combat  tuberculosis  among  the  colored  ele- 
ment of  the  population. 


TABLE  32 

DEATH-RATES  FROM   ALL   FORMS   OF   TUBERCULOSIS  IN 
"CITY  A,"    1911-1920,   DISTRIBUTED   ACCORDING 

TO    NATIONALITY 


Specific 
death-rate 
in  city  A. 

Specific-death  rates  among 

Year. 

Irish. 

Scandina- 
vians. 

Italians. 

Hebrews. 

Poles. 

1911 

1912 

1913 

1914 

1915 

1916 

1917 

1918 

1919 

1920 

The  number  of  nationalities  listed  is  not  complete. 
Those  selected  are  simply  used  as  examples,  and  others 
may  be  added  or  substituted. 


DEATHS   FROM   ALL   FORMS 


263 


TABLE  33 

PERCENTAGE  OF  DEATHS  FROM  ALL  FORMS  OF  TUBERCU- 
LOSIS IN   "CITY  A,"  DISTRIBUTED   ACCORDING   TO 

NATIONALITY 


Total 
number  of 

deaths 
trom  tuber- 
culosis. 

Percentage  of  all  deaths  from  tuberculosis  among 

Year. 

Irish. 

Scandina- 
vians. 

Italians. 

Hebrews. 

Poles. 

1911 

1912 

1913 

1914 

1915 

1916 

1917 

1918 

1919 

1920 

• 

• 

TABLE   34 

DEATHS  FROM  ALL  FORMS  OF  TUBERCULOSIS  IN  "  CITY  A," 
1911-1920,   DISTRIBUTED   ACCORDING   TO   AGE 


Year. 


1911 

1912 
1913 
1914 
1915 
1916 
1917 
1918 
1919 
1920 


Under 
1 


Under 
5 


5-9 


10-14 


15-19 


20-24 


25-34 


35-44 


45-54 


55-64 


65-74 


75  and 
over. 


264 


TUBERCULOSIS 


TABLE  35 

DISTRIBUTION   OF  DEATHS   FROM   TUBERCULOSIS   OF  ALL 
FORMS   IN   "CITY   A,"    1911-1920,   ACCORDING   TO 

OCCUPATION 


Occupation. 


Per  cent  of  total. 


Measures  for  the  Control  of  Tuberculosis 

Various  measures  contribute  to  the  control  of  tuber- 
culosis, since,  as  has  already  been  indicated  earlier  in  the 
chapter,  its  prevalence  is  related  to  almost  every  phase  of 
community  life.  The  control  of  this  disease  therefore  in- 
volves an  extensive  public  health  campaign.  The  first 
step,  however,  is  to  find  the  cases  and  place  them  under 
proper  supervision  at  home,  or  to  remove  them  to  hos- 
pitals and  sanatoria  where  they  can  receive  adequate  and 
satisfactory  treatment,  and  where  it  is  impossible  for  them 
to  infect  others.  It  is  also  important  to  educate  the  tuber- 
culous in  the  precautions  necessary  to  prevent  spreading 
the  disease,  and  in  proper  methods  of  caring  for  themx- 
selves,  so  that  they  may  regulate  their  lives  accordingly. 
The  general  public,  too,  must  be  made  to  understand  how 
tuberculosis  is  spread  and  how  the  vital  resistance  of  the 
body  can  be  maintained  at  the  highest  level.     The  im- 


MEASURES  FOR  CONTROL  OF  TUBERCULOSIS      265 

portance  of  maintaining  a  high  degree  of  vital  resistance 
cannot  be  over-emphasized.  Finally,  it  is  necessary  to 
conduct  an  active  and  continuous  campaign  to  promote 
the  general  public  health  of  the  community,  in  order  to 
aid  the  people  to  avoid  infection  and  to  maintain  their 
vital  resistance. 


Fig.  9L     A  tuberculous  patient  living  under  crowded  and  unsanitary 
conditions,  receiving  a  visit  from  a  neighbor. 


There  are  other  important  elements  in  the  control  of 
tuberculosis,  which  have  not  been  mentioned,  since  they 
are  details  and  must  be  taken  for  granted.  For  example, 
such  items  as  complete  and  satisfactory  reporting  of  cases, 
and  the  education  of  physicians  in  the  early  and  correct 
diagnosis  of  tuberculosis  are  extremely  important.  The 
efforts  made  to  induce  people  to  come  to  dispensaries  for 
examination,  and  the  results  obtained,  the  character  of 
the  educational  campaign,  and  the  steps  taken  to  secure 
proper  treatment  and  freedom  from  worry  for  the  tuber- 
culous and  thair  families  —  all  these  things  must  be  con- 
sidered  as   factors   affecting  the   control   of  tuberculosis. 


266  TUBERCULOSIS 

Recently,  the  open-air  school,  the  day  camp,  the  nutrition 
class  and  the  health  crusader  movement  have  been  added 
as  aids  in  the  campaign  against  tuberculosis.  These  activi- 
ties aim  to  combat  the  disease  either  through  education, 
through  the  upbuilding  of  the  vitality  of  the  child  or 
through  both  methods  combined. 

Another  aspect  of  the  problem  with  which  tuberculosis 
workers  are  confronted  is  the  care  and  control  of  wander- 
ing and  homeless  cases.  These  poor  mortals,  who  often 
succeed  in  transmitting  infection  to  other  people,  are 
driven  from  one  place  to  another.  Often  they  are  phy- 
sically too  weak  to  work,  and,  as  a  result,  frequently  become 
objects  of  charity,  thus  constituting  a  vexing  problem  to 
the  public  and  private  charities,  as  well  as  a  serious  public 
health  problem. 

These  points  are  mentioned  to  bring  to  the  mind  of  the 
surveyor  the  various  aspects  of  the  problem  that  must  be 
considered.  Most  of  these  points  will  be  considered  below 
in  more  detail.  Some  of  them,  such  as  the  open-air  school 
and  the  nutrition  class,  have  already  been  discussed  in  other 
chapters. 

The  Tuberculosis  Dispensary 

How  many  tuberculosis  dispensaries  exist  in  the  city? 
When  was  each  founded?  Where  is  each  located?  By 
whom  is  each  supported  ?  How  many  public  health  nurses 
are  employed  at  each  dispensary  ?     How  many  physicians  ? 

How  often  are  clinics  held?  When  do  these  occur? 
Are  any  clinics  held  at  night?  How  are  patients  for  the 
clinic  obtained?  Are  examinations  free?  If  not,  what 
amount  is  each  patient  required  to  pay? 

Is  each  patient  given  a  thorough  physical  examination? 
Is  the  sputum  examined  ?  Is  an  X-ray  photograph  taken  ? 
Are  any  other  laboratory  tests  made?  Are  the  patients 
required  to  pay  for  these  tests?     If  so,  how  much?     Is  a 


THE   TUBERCULOSIS   DISPENSARY 


267 


complete  history  of  each  case  obtained  and  kept  on  record? 
Is  the  progress  of  each  case  also  kept  on  record?  The 
surveyor  should  examine  these  records  and  classify  them 
according   to   age,   sex,   occupation   and   nativity.     These 


Fig.  92.  View  of  a  children's  clinic  at  the  tuberculosis  dispensary 
maintained  by  the  Oklahoma  City  Anti-Tuberculosis  Society.  All 
children  exposed  to  tuberculosis  at  home  visit  the  dispensary  at  periodic 
intervals  for  weighing  and  examination. 

tables  can  be  arranged  in  a  manner  similar  to  those  dealing 
with  the  deaths  from  tuberculosis,  and  given  earlier  in  the 
chapter.  The  results  of  the  examinations  can  be  tabulated 
in  the  manner  indicated  below. 


268 


TUBERCULOSIS 


TABLE  36 

RESULTS  OF  DISPENSARY  EXAMINATION  OF  PATIENTS  FOR 

TUBERCULOSIS,    CLASSIFIED    ACCORDING    TO    AGE, 

SEX   AND    STAGE    OF   DISEASE 


Tuber- 

Age. 

Sex. 

culosis 

Stage 

Stage 

Stage 

Doubt- 

Non 

Nega- 

of 

I. 

II. 

III. 

ful. 

T.  B. 

tive. 

Hilus. 

Under  5 .  .  .  . 

M. 
F. 

5-15 

M. 
F. 

15-35 

M. 
F. 

35  and  over. 

M. 
F. 

Total 

Tola! 


One  of  the  most  important  functions  of  the  tuberculosis 
dispensary  is  to  discover  early  and  doubtful  cases.  Inas- 
much as  tuberculous  infection  is  likely  to  take  place  dur- 
ing childhood,  it  is  exceedingly  important  that  a  large 
number  of  children  be  examined.  Those  children  in  whose 
families  there  are  known  cases  of  tuberculosis  should  cer- 
tainly be  examined.  It  is  also  important  to  examine  all 
who  have  been  in  contact  with  known  cases  of  tuberculosis. 
In  that  way  it  will  be  possible  to  discover  early  cases  and 
to  take  adequate  measures  for  their  treatment. 

Each  table  should  l)e  discussed  thoroughly  and  the  sig- 
nificance of  the  results  should  be  clearl}'  indicated  and  inter- 
preted, wherever  necessary. 

The  answers  to  the  following  questions  should  also  be 
obtained,  in  considering  the  tuberculosis  dispensary. 

Do  the  public  health  nurses  make  home  visits?  How 
many  visits'  were  made  during  the  past  year?     How  many 


THE  TUBERCULOSIS   HOSPITAL  269 

of  these  visits  are  made  to  dispensary  patients?  How- 
many  visits  are  made  to  patients  too  ill  to  come  to  the 
dispensary?  What  is  the  nature  of  the  nurses'  work  on 
these  visits?  Are  the  patients  educated  in  the  methods  of 
preventing  the  spread  of  infection?  Is  this  done  through 
demonstrations  and  personal  instruction,  or  through  the 
use  of  printed  material?  What  precautions  are  taken  to 
protect  other  members  of  the  family? 

Are  arrangements  made  to  provide  each  patient  with 
plenty  of  air,  sunshine  and  good  food?  Are  patients  re- 
quired to  stay  in  bed  for  any  definite  period?  What  pro- 
vision is  made  for  furnishing  material  aid  to  the  needy? 
From  what  source  does  this  aid  come?  To  what  extent 
have  cases  of  tuberculosis  been  aided  during  the  past  year? 

The  Tuberculosis  Hospital  or  Sanatorium 
The  Building 

What  is  the  name  of  the  sanatorium?  Where  is  it 
located?  When  was  it  built?  Is  it  a  private,  municipal, 
county  or  state  institution?  Are  the  patients  required  to 
pay  for  treatment?  If  so,  what  are  the  rates?  What 
arrangement  is  made  for  treating  charity  patients?  Is  the 
location  of  the  sanatorium  pleasant,  quiet  and  generally 
desirable  ? 

Of  what  material  is  the  sanatorium  built?  Is  the  build- 
ing fireproof?  How  many  stairways  and  inclined  passage- 
ways are  available?  Where  are  they  located?  W^hat 
other  precautions  are  taken  to  insure  the  patients  against 
danger  from  fire?     How  many  stories  are  there? 

Wards  and  Beds 

How  many  wards  are  there  in  the  sanatorium?  How 
many  beds  in  each  ward?  How  many  single  rooms  are 
there?     How   many   double   rooms?     What   is   the   total 


270  TUBERCULOSIS 

number  of  beds  available?  Are  the  wards  large,  light, 
and  well  ventilated?  Is  overcrowding  avoided?  Are  the 
single  rooms  large,  light,  and  well  ventilated? 

Are  the  toilet  facilities  in  the  wards  satisfactory  and 
convenient?  Are  the  facilities  in  the  single  rooms  satis- 
factory? Are  bathing  facilities  provided  for  the  wards? 
Are  they  conveniently  located?  Are  bathing  facilities 
provided  for  the  single  rooms?  Are  they  conveniently 
located  ? 

Are  the  wards  and  single  rooms  thoroughly  screened? 
Are  the  wards  and  single  rooms  satisfactorily  provided  with 
artificial  light?  Are  sun-porches  provided?  Are  these 
porches  equipped  with  comfortable  chairs  or  beds? 

Cases 

How  many  cases  were  under  treatment  at  the  time  of 
inspection?  In  what  stage  of  the  disease  must  cases  be 
in  order  to  be  admitted?  What  is  the  normal  period  of 
time  for  patients  to  remain  in  the  sanatorium?  What  is 
the  minimum  period  of  time?  What  is  the  maximum 
period  of  time?  How  many  arrested  cases  of  the  disease 
have  been  released  since  the  sanatorium  was  founded?  Is 
any  attempt  made  to  guide  these  persons  into  proper  occu- 
pations? Is  any  follow-up  work  done  in  such  cases?  Are 
any  statistics  available  regarding  the  number  that  break 
down  after  returning  to  the  normal  life  of  the  community? 

Is  each  patient  thoroughly  examined  before  admission? 
Does  the  examination  include  a  bacteriological  diagnosis, 
an  X-ray  examination,  and  a  thorough  physical  examina- 
tion? Are  other  tests  made?  If  so,  what  are  they?  Is 
each  new  patient  subjected  at  first  to  any  special  treatment, 
such  as  prolonged  or  even  continuous  rest?  Does  each 
case  receive  separate  and  special  attention?  Is  each 
patient  provided  with  sufficient  clothing  and  blankets  to 
keep  warm  during  cold  weather?     What  arrangements  are 


THE  TUBERCULOSIS  HOSPITAL  271 

available  for  giving  patients  exercise  and  work,  when  they 
are  ready  for  either  ?  What  is  done  to  keep  up  the  morale, 
spirits  and  hopes  of  the  patients  ? 

The  surveyor  should  study  the  records  of  the  cases  that 
have  been  treated  at  the  sanatorium  in  order  to  throw  more 
light  on  what  has  been  done.  These  records  should  also 
be  analyzed  statistically,  as  the  results  may  yield  some 
interesting  conclusions. 

Disinfection  and  Laundry 

What  methods  are  employed  for  disinfecting  bed-linen, 
eating-utensils,  and  other  materials  that  come  into  con- 
tact with  the  patient?  What  methods  are  employed  for 
collecting  and  disinfecting  the  sputum  of  patients?  Are 
linen  handkerchiefs  used?  How  are  these  collected, 
washed  and  sterilized? 

Laboratory  Facilities 

Is  there  a  bacteriological  and  pathological  laboratory  on 
the  premises?  If  not,  is  one  available?  Is  it  conven- 
iently located?  Does  the  sanatorium  maintain  an  X-ray 
laboratory  ?  If  not,  is  such  a  laboratory  available  for  use  ? 
Is  it  conveniently  located?  If  laboratory  facilities  are 
available,  are  they  adequate  and  satisfactory?  What 
tests  are  made?  Who  performs  them?  Are  the  labora- 
torians  trained  for  this  work? 

Heating  and  Ventilation 

This  subject  is  not  very  important  in  the  consideration 
of  tuberculosis  sanatoria,  as  almost  all  of  the  patients  in 
such  institutions  live  out-of-doors  during  the  day,  or  else 
live  in  rooms  which  are  constantly  open,  and  hence  are 
thoroughly  ventilated  by  natural  methods. 


272  TUBERCULOSIS 

Kitchen 

The  study  of  the  kitchen  need  not  be  extensive.  The 
surveyor  should  consider  its  location,  the  method  by  which 
food  is  distributed,  and  the  degree  of  cleanliness  in  the 
preparation  and  handling  of  the  food  and  in  the  kitchen 
itself. 

Open-Air  Schools 

The  question  of  open-air  schools  has  been  adequately 
considered  in  the  chapter  dealing  with  school  hygiene. 
The  student  of  the  subject  is  referred  to  that  chapter  for 
the  information  that  should  be  obtained  under  that  head. 

Day  Camps 

Day  camps  and  other  measures  for  aiding  the  tuber- 
culous should  be  studied  thoroughly.  Special  attention 
should  be  given  to  the  sanitary  facilities  available,  the 
medical  supervision  of  those  who  attend,  the  question  of 
adequate  rest,  and  protection  from  the  elements,  and  the 
problem  of  an  adequate  and  wholesome  diet. 

Education 

Under  this  head,  the  surveyor  should  determine  the 
extent  and  the  nature  of  the  educational  work  which  is 
conducted  in  the  fight  against  tuberculosis.  The  following 
questions  will  indicate  the  information  desired. 

Who  is  responsible  for  the  educational  activities  against 
tuberculosis?  Are  tuberculosis  nurses  employed?  Is  a 
comprehensive  lecture  system  maintained?  Are  talks 
given  in  the  factories,  the  large  stores,  and  the  schools, 
and  at  the  meetings  of  the  various  social  and  business 
clubs,  the  labor  unions  and  the  religious  and  other  organi- 
zations that  may  exist  in  the  community?     Are  moving 


OUTLINE  OF  CHAPTER  273 

pictures  employed?  Are  stereopticon  views  used  with  the 
lectures,  and  shown  in  the  moving  picture  theaters?  Are 
exhibits  maintained  and  shown  at  large  meetings,  fairs  or 
other  large  assemblies  of  people?  Are  newspaper  articles 
on  tuberculosis  or  on  the  activities  of  the  tuberculosis 
association  published  regularly  and  frequently?  Are 
newspaper  advertisements  used  to  create  interest  and 
disseminate  information  on  tuberculosis?  Are  leaflets, 
posters,  booklets  and  other  printed  matter  dealing  with 
tuberculosis  distributed  regularly  to  the  people  without 
charge?  Is  the  Modern  Health  Crusader  movement 
actively  supported  and  vigorously  conducted  in  the 
schools  ? 

In  every  case,  the  surveyor  should  determine  the  extent 
to  which  these  activities  are  conducted,  and  should  obtain 
samples  of  the  publicity  and  educational  material  wherever 
possible,  not  only  for  further  study  and  criticism,  but  also 
for  the  purpose  of  including  them  in  the  report.  The 
surveyor  should  also  ascertain  whether  monthly  and  annual 
reports  are  published.  If  such  is  the  case,  copies  of  these 
should  be  obtained  and  studied  carefully. 

OUTLINE   OF   CHAPTER   ON   TUBERCULOSIS 

1.  General  statement  of  the  importance  and  difficulty  of  combating 
tuberculosis.  Tuberculosis  is  intimately  related  to  the  general  public 
health  problem  and  with  social  and  economic  conditions.  It  cannot 
be  considered  alone. 

2.  Growth  of  the  anti-tuberculosis  movement.  National,  state  and 
municipal  associations;  hospitals  and  sanatoria;  dispensaries;  tuber- 
culosis nursing;  educational  propaganda;  open-air  classes  and  schools; 
day  camps;   nutrition  classes;   better  working  conditions  in  industry. 

3.  Statistical  study  of  tuberculosis;  death-rate;  prevalence  of 
tuberculosis;  reporting  of  deaths;  reporting  of  active  cases;  compari- 
son of  death-rates  with  those  of  other  cities  and  with  the  rates  for  all 
the  cities  in  the  U.  S.  Registration  Area;  distribution  of  death-rates 
according  to  color,  age,  nationality,  sex,  occupation;    distribution  of 


274  TUBERCULOSIS 

cases  according  to  color,  age,  nationality,  sex,  occupation  and  stage  of 
the  disease. 

4.  Measures  for  the  control  of  tuberculosis;  discussion  of  the  activi- 
ties of  agencies  combating  tuberculosis. 

5.  Summary. 

6.  Recommendations. 


CHAPTER  XVI 
VITAL   STATISTICS 

Accurate  and  Complete  Vital  Statistics  are  Essential  to 
Public  Health  Work.  —  Just  as  any  well-organized  business 
keeps  a  record  of  its  liabilities  and  assets,  and  can  show 
the  exact  status  of  the  enterprise  at  any  given  time,  so  it 
is  necessary  for  a  community  to  know  its  liabilities  and 
assets  regarding  health  and  disease.  This  necessitates  the 
keeping  of  accurate  and  complete  records  as  to  the  popu- 
lation, the  number  of  births,  the  number  of  deaths,  the 
causes  of  death,  distribution  of  deaths  according  to  age, 
sex,  and  occupation,  together  with  other  items  that  are 
usually  included  under  the  head  of  vital  statistics.  The 
vital  statistics  of  a  community  serve  as  the  bookkeeping 
of  the  health  of  the  people,  and  the  growth  of  the  city. 

It  has  been  truly  said  by  various  health  authorities,  that, 
^'within  certain  limits,  a  community  can  determine  its 
own  death-rate."  By  this  is  meant  that  with  adequate 
funds,  properly  and  wisely  expended,  a  community  can 
lower  its  death-rate  to  within  certain  limits,  which  may  be 
expected  to  exist  under  the  most  ideal  conditions.  But  if 
the  reporting  of  births,  deaths  and  cases  of  disease  is  in- 
accurate and  incomplete,  it  will  be  impossible  to  calculate 
the  true  death-rate,  and  to  determine  which  diseases  con- 
stitute the  greatest  menace  to  the  population.  Without 
adequate  knowledge  of  the  prevalence  of  the  various  dis- 
eases in  a  community,  it  is  impossible  to  marshal  the 
forces  of  prevention  intelligently  and  effectively,  in  order 
that  the  diseases  of  man  may  be  fought  and  overcome. 
Without  such  information,  it  is  also  impossible  to  deter- 

275 


276  VITAL  STATISTICS 

mine  the  exact  lines  along  which  the  public  funds  should 
be  expended.  Should  the  money  be  spent  in  preventing 
nuisances  due  to  exposed  garbage  or  manure,  or  in  pro- 
tecting the  milk-supply?  Should  funds  be  set  aside  for 
preventing  infant  deaths,  typhoid  fever,  malaria,  tuber- 
culosis, pneumonia  or  other  diseases,  or  for  housing  inspec- 
tion, or  inspection  of  food-stores  and  restaurants,  or  for 
some  other  phase  of  the  public  health  activities?  An 
analysis  of  the  complete  and  accurate  vital  statistics  of  a 
community  will  enable  us  to  determine  not  only  the  activi- 
ties which  should  claim  the  public  funds,  but  also  the 
amount  of  money  which  should  be  spent  in  each  direction. 
It  is  obvious  that  if  one  disease  is  more  prevalent  than 
another,  and  is  causing  more  deaths,  that  disease  should 
receive  more  attention  and  should  feel  the  weight  of  the 
public  health  campaign  in  a  greater  measure. 

Incomplete  Reporting  of  Births  and  Deaths  has  Caused 
the  Establishment  of  Registration  Areas.  —  Unfortunately, 
the  vital  statistics  of  the  nation  at  large  are  not  sufficiently 
accurate  and  complete  to  be  considered  reliable.  It  has 
therefore  become  necessary  for  the  Federal  Bureau  of 
Census  to  devise  a  registration  area  for  deaths  and  a  regis- 
tration area  for  births.  In  each  area,  the  reporting  of 
births  or  of  deaths  is  sufficiently  complete  and  accurate 
to  be  considered  reliable.  Sometimes  entire  states,  like 
Oklahoma  and  Texas,  are  excluded  from  the  registration 
area,  because  their  vital  statistics  are  not  reliable.  How- 
ever, certain  cities  in  such  states,  which  have  developed 
a  satisfactory  degree  of  accuracy  and  completeness  in  their 
vital  statistics  may  be  admitted  to  the  registration  area. 

Methods  for  Judging  Completeness  and  Accuracy  of 
Reporting.  —  One  of  the  first  things  which  the  surveyor 
must  do  in  studying  the  vital  statistics  of  a  community, 
is  to  determine  whether  the  city  is  in  the  registration  area 
either  for  births  or  deaths,  or  both.     He  must  also  deter- 


MORBIDITY  FROM   COMMUNICABLE   DISEASES      277 

mine  whether  or  not  all  cases  of  communicable  disease  are 
reported.  Some  information  on  this  point  can  usually  be 
obtained  from  the  health  officer.  However,  an  affirmative 
answer  should  not  be  regarded  as  proof  that  all  com- 
municable diseases  are  being  reported. 

Several  methods  may  be  employed  to  verify  the  informa- 
tion given  by  the  health  officer,  or  to  obtain  it  without  his 
help.  The  surveyor  or  his  assistants  may  visit  every  phy- 
sician in  the  city  and  learn,  if  possible,  the  number  of 
cases  of  communicable  disease  under  treatment,  and  the 
nature  of  the  disease  in  each  case.  This  list  could  then 
be  compared,  for  completeness  and  accuracy,  with  the 
records  at  the  office  of  the  health  department.  If  the 
attempt  is  made  to  check  up  the  official  records  in  this 
way,  it  is  important  to  bear  in  mind  that  each  physician 
should  be  personally  interviewed.  An  attempt  to  obtain 
the  necessary  information  by  correspondence  or  telephone 
will  be  almost  certain  to  meet  with  failure.  The  facts 
obtained  should  be  recorded  on  form-cards  like  the  one 
reproduced  below. 

MORBIDITY   FROM   COMMUNICABLE   DISEASES 

Name  of  Disease 

Date  of  Onset 

Name  of  Patient 

Address Ward 

Age Sex Color 

Name  of  Physician 

Source  of  I nf ormation 


Another  method  for  determining  whether  cases  of  com- 
municable disease  are  accurately  and  completely  reported, 


278  VITAL  STATISTICS 

and  one  which  is  perhaps  most  frequently  used,  since  it  is 
the  most  convenient,  is  to  compare  the  number  of  cases  of 
disease  reported,  with  the  number  of  deaths  from  the  same 
disease.  If  the  cases  of  disease  are  approximately  equal 
to  the  number  of  deaths  from  the  same  disease,  or  are  less 
than  that  number,  it  is  apparent  that  all  the  cases  of  dis- 
ease have  not  been  reported.  The  normal  ratio  between 
the  number  of  active  cases  and  the  number  of  deaths  has 
been  determined  for  some  diseases.  It  is  known,  for  ex- 
ample, that  for  every  death  from  typhoid  fever  or  from 
tuberculosis,  there  should  be  about  ten  cases  of  the  same 
disease.  If  the  difference  between  the  existing  ratio  and 
this  established  ratio  is  very  marked,  it  is  almost  certain 
that  all  the  cases  are  not  being  reported. 

There  is  still  another  method  for  judging  communicable 
disease  records,  which  is  also  applicable  to  records  of 
births  and  deaths.  This  method  consists  in  obtaining 
reliable  vital  statistics  for  other  communities  and  comparing 
them  with  those  that  are  available  for  the  city  under  con- 
sideration. The  following  precautions,  however,  must  be 
observed.  The  cities  which  are  compared  should  prefer- 
ably be  located  in  the  same  section  of  the  country.  They 
should  also  have  approximately  the  same  population,  and 
a  similar  age,  sex  and  race  distribution.  If  possible,  they 
should  have  health  organizations  which  are  recognized  as 
superior  to  that  in  the  city  under  consideration.  Where 
these  conditions  cannot  readily  be  fulfilled,  it  is  desirable 
to  make  comparisons  with  other  cities  of  the  same  size  in 
other  parts  of  the  country,  or,  better  yet,  with  larger  cities 
in  the  same  section  of  the  country,  where  the  conditions 
of  life  and  environment  are  similar. 

In  these  various  ways  it  will  be  possible  to  ascertain 
whether  the  vital  statistics  are  complete,  accurate  and 
reliable.  Very  often,  they  may  be  found  to  be  hopelessly 
inaccurate  and  incomplete,  and  the  surveyor  may  wonder 


REPORT  OF   DEATHS  279 

whether  or  not  it  is  desirable  to  waste  time  on  the  figures 
that  are  available.  Considerable  good  will  probably  be 
done  by  showing  very  plainly  that  the  existing  statistics 
are  woefully  inaccurate.  It  is  better  to  study  the  statistics 
that  are  available  than  to  ignore  the  subject  entirely,  as  it 
is  much  more  enlightening  to  a  community  to  know  how 
unreliable  its  statistics  are  than  to  remain  entirely  ignorant 
of  their  condition. 

Under  Certain  Conditions  the  Original  Death  Certificates 
should  be  Studied.  —  Unless  the  statistics  have  already 
been  completely  analyzed,  the  surveyor  will  find  it  profit- 
able to  examine  the  original  death  certificates.  He  can 
determine  in  this  way  whether  these  certificates  were  filled 
out  completely,  whether  the  primary  cause  of  death  was 
given  correctly,  or  whether  the  real  primary  cause  was 
given  as  the  secondary  cause.  He  will  also  be  able  to 
determine  the  age,  sex,  race,  and  occupation  of  the  de- 
ceased, and,  in  this  way,  can  analyze  the  deaths  in  a  most 
interesting  way.  Such  a  study  is  extremely  valuable  and 
throws  considerable  light  on  the  public  health  activities 
that  should  be  stressed.  If  it  is  necessary  to  transcribe 
the  information  from  the  original  death  certificates,  the 
following  form  card  may  be  found  to  be  of  value 


REPORT  OF  DEATHS 

Cause  of  Death Date 

Name 

Address Ward. . . 

Age Sex ,     Color. 

Occupation 

Physician 


•  •  •  •  • 


280  VITAL  STATISTICS 

Responsibility  for  Vital  Statistics  should  Rest  with 
Health  Oiiicer  Alone.  —  The  responsibility  for  the  vital 
statistics  is  frequently  divided.  Sometimes  the  births  and 
deaths  are  reported  to  the  county  health  officer,  and  the 
cases  of  comnuuiica})le  disease  to  the  local  health  officer. 
In  other  cases  some  of  the  items  are  reported  to  the  city 
clerk,  and  the  rest  to  the  health  officer.  Both  of  these 
systems  are  undesirable  and  objectionable.  Not  only 
does  a  division  of  responsibility  for  the  statistics  serve  to 
confuse  the  physicians  and  tend  to  make  them  lax  in  re- 
porting, but  it  often  deprives  the  health  officer  of  the  only 
definite  way  of  knowing  the  prevalence  of  disease  and  the 
number  of  ])irths  and  deaths  that  are  occurring.  The 
result  is  that  the  statistics  are  not  analyzed  and  that  the 
activities  of  the  health  department,  instead  of  being  based 
on  the  relative  prevalence  of  various  .diseases  and  the 
number  of  deaths  they  cause,  are  conducted  on  some  other 
basis  which  cannot  be  as  sound.  The  health  officer  should 
legally  be  the  registrar  of  vital  statistics,  and  he  alone 
should  be  responsible  for  them.  They  are  essential  to 
intelligent  work  on  his  part,  and,  therefore,  justly  belong 
under  his  jurisdiction. 

Statistics  should  Cover  a  Period  of  at  Least  Five 
Years.  —  One  of  the  questions  that  will  come  to  the  mind 
of  every  surveyor  concerns  the  number  of  years  for  which 
the  statistics  should  be  studied.  A  reasonable  answer 
would  be  that  the  statistics  studied  should  cover  as  many 
years  as  possible,  for  the  longer  the  period  covered,  the 
more  valuable  will  the  results  be,  if  they  are  interpreted 
correctly.  The  statistics  concerning  births,  deaths,  and 
cases  of  communicable  disease  should  cover  a  period  of  at 
least  five  years.  Wherever  possible,  statistics  covering  a 
longer  period  of  time  should  be  studied. 

Statistics  should  be  Graphically  Illustrated.  —  In  pre- 
senting the  vital  statistics,  tables,  graphs  and  charts  should 


POINTS   TO   BE   INCLUDED  281 

be  used  extensively.  The  proper  graphical  representation 
of  the  data  at  hand  will  do  more  to  make  them  real  and 
vital  than  a  mere  statement  of  the  figures.  If  the  sur- 
veyor is  not  acquainted  with  the  various  methods  of 
representing  facts  graphically,  he  is  urged  to  study  other 
survey  reports,  annual  reports  of  health  departments, 
reports  of  business  and  banking  organizations  or  books  on 
vital  statistics,  besides  making  a  special  study  of  graphical 
methods. 

Law  Governing  Vital  Statistics  should  be  Studied  before 
Investigation  Begins.  —  Before  beginning  the  actual  study 
of  the  vital  statistics,  the  surveyor  should  determine 
whether  the  model  reporting  law  of  the  Bureau  of  Census 
has  been  adopted  in  the  state,  and  whether  it  is  in  opera- 
tion in  the  city  under  consideration.  At  any  rate,  the 
requirements  of  the  existing  law  should  be  carefully  studied 
and  criticized  or  commended,  as  the  situation  warrants. 

Some  Information  Regarding  the  Vital  Statistics  Desir- 
able Prior  to  Field  Survey.  —  The  study  of  the  vital  statis- 
tics is  primarily  an  office  investigation,  and  can  be  made 
either  before  or  after  the  field  survey  work  has  been  com- 
pleted. If  possible,  however,  some  information  on  the 
vital  statistics  and  the  prevailing  mortality,  morbidity, 
and  birth-rates  should  be  obtained  at  the  beginning  of  the 
survey.  In  this  way,  the  surveyor's  attention  may  be 
directed  to  certain  conditions  which  are  in  need  of  improve- 
ment, and  his  investigation  of  them  will  be  particularly 
thorough. 

Points  to  be  Included  in  the  Study  of  the  Vital  Statistics. 
—  The  points  which  should  be  considered  in  a  study  of 
vital  statistics  are  given  below.  The  methods  employed 
in  making  the  study  are  discussed  separately  under  each 
subject. 


282  VITAL  STATISTICS 

Population 

The  character  of  the  population,  its  condition  as  regards 
wealth  and  education,  its  race,  sex,  and  age  distribution, 
the  predominating  industries,  and  the  rapidity  with  which 
the  population  has  increased  are  all  factors  which  affect 
the  death-rate  of  a  community.  It  is  therefore  exceedingly 
important  to  know  as  much  about  the  increase  and  com- 
position of  the  population  as  the  available  statistics  will 
reveal.  Another  reason  why  accurate  knowledge  of  the 
population  is  essential  is  that  almost  all  the  vital  statistics, 
such  as  birth-rates,  death-rates,  specific  death-rates  and 
morbidity  rates,  are  based  on  the  total  population.  If  the 
population  statistics  are  inaccurate,  the  calculated  death- 
rates,  birth-rates  and  morbidity  rates  must  necessarily 
also  be  inaccurate. 

The  best  and  most  accurate  sources  of  information  re- 
garding the  population  of  cities  in  the  United  States  are 
the  reports  of  the  Bureau  of  Census.  As  a  new  census  is 
taken  only  once  every  ten  years,  the  population  of  a  city 
during  inter-census  years  must  be  estimated  from  the 
rate  of  growth  observed  during  preceding  decades.  This 
rate  can  be  determined  by  either  the  arithmetic  or  the 
geometric  method,  or  by  comparing  the  cit}^  in  question 
with  other  cities  that  aVe  larger,  and  observing  the  rate  of 
growth  of  these  cities  when  they  had  the  same  population. 

In  certain  instances,  such  as  the  development  of  ''mush- 
room "  cities,  hardly  any  method  of  estimation,  other 
than  a  direct  enumeration  of  the  population,  will  yield 
exact  knowledge  regarding  the  total  population.  The 
arithmetic  method  of  estimating  the  population  is  usually 
the  best,  and  is  the  method  most  frequently  employed. 
Some  states  conduct  a  special  census,  five  years  after  the 
Federal  census;  and  the  figures  obtained  are  usually  re- 
liable enough  to  enable  the  surveyor  to  determine,  with 


POPULATION  OF  CITY  283 

sufficient  accuracy,  the  population  of  any  city  in  the  state 
during  the  inter-census  period.  In  quoting  the  population 
of  cities  to-day,  the  United  States  census  figures  for  1890 
to  1920  should  be  recorded. 

The  following  table  illustrates  how  the  population  should 
be  recorded. 


TABLE  37 
POPULATION    OF   "CITY 

A" 

Year. 

Population. 

1890 

1900 

1910 

1920 

Year  of  study  (estimated) 

After  recording  the  population  in  the  above  table,  it  is 
desirable  to  show,  in  a  graphic  manner,  the  rate  of  growth 
since  1890.  The  block  chart  is  recommended  as  an  easy 
and  satisfactory  method  of  demonstrating  the  rate  of 
growth.  Any  striking  fact  in  the  make-up  or  growth  of 
the  population  should  be  a  subject  for  comment  in  the 
report. 


284 


VITAL  STATISTICS 


POPULATION    1890-1018. 


1890 


1900       1907 

Fig.  93. 


1910 


1918 


The  composition  of  the  population,  according  to  color, 
at  the  tini(^  of  the  last  census,  can  be  recorded  in  the  fol- 
lowing table. 

TABLE  38 
COMPOSITION    OF   POPULATION,    ACCORDING    TO    COLOR 


ropululion. 

Per  cent. 

Total 

100 

White 

Negro 

Monf^cjlian 

COMPOSITION   OF  POPULATION 


285 


The  composition  of  the  population  according  to  sex,  at 
the  time  of  the  last  census,  can  be  recorded  in  the  following 
table. 


COMPOSITION  OF  POPULATION,   1910,  BY  RACE  AND  SEX. 


tnd 


lan 


Black 


■V\"hite 


'■'*"-"7 


White 
Females 


Black 
Females 


V  \ 


i^AVl 


'v; 


:'^e 


White 
Males 


Black 
Males 


FiQ.  94. 


286 


VITAL  STATISTICS 


TABLE  39 
COMPOSITION  OF  POPULATION  ACCORDING  TO  SEX 


Color. 

Males. 

Females. 

Per  cent 
males. 

Per  cent 
females. 

White 

Negro 

The  two  tables  just  quoted  can  be  illustrated  graphically 
by  bar  charts,  reproduced  from  the  Oklahoma  City  Public 
Health  Survey,  in  the  manner  indicated  above. 


General  Death-Rates 

It  is  usually  possible  to  tell,  in  a  general  way,  what  the 
health  conditions  in  a  city  are,  by  examining  the  general 
death-rates.  Although  such  factors  as  climate,  age-distri- 
bution, sex-distribution,  race-distribution,  wealth,  intelli- 
gence and  public  health  protection  all  affect  the  general 
death-rate,  and  make  it  difficult  to  compare  the  rates  of 
one  city  with  another,  yet  to  a  certain  extent  such  a  com- 
parison of  rates  is  of  considerable  value.  The  comparison 
is  especially  valuable  if  the  rates  for  other  cities  which  are 
as  closely  similar  as  possible  and  which  are  in  the  same 
geographical  area,  are  considered.  Where  the  age  distri- 
bution, in  the  cities  compared,  is  not  verj^  similar,  it  is 
sometimes  desirable  to  standardize  the  death-rates.  It 
may  also  be  desirable  to  compare  the  existing  death-rate 
in  the  community  under  consideration  with  the  rates  that 
prevail  in  the  United  States  Registration  Cities.  These 
rates  can  also  be  obtained  from  the  census  reports. 

The  following  table  shows  the  manner  in  which  the 
information  should  appear. 


GENERAL   DEATH-RATES 


287 


TABLE  40 

DEATHS  AND  DEATH-RATES  FROM  ALL  CAUSES  IN  "  CITY  A" 
AND    OTHER    CITIES,    1911-1920,    RATES   PER   1000 

POPULATION 


Popula- 
tion. 

City  A. 

City 
B. 

Citv 
C. 

Year. 

Number  of 
deaths 
from  all 
causes. 

Death- 
rate. 

U.  S.  reg- 
istration 
cities. 

Citv 
D. 

1911 

1912 

1913 

1914 

1915 

1916 

1917 

1918 

1919 

1920 

' 

The  data  recorded  in  the  above  table  should  be  analyzed 
and  discussed.  From  this  table,  the  surveyor  should  be 
able  to  determine  whether  or  not  all  the  deaths  are  being 
reported.  If  the  death-rates  in  the  city  under  considera- 
tion are  materially  lower  than  those  in  the  neighboring 
cities  which  are  used  in  the  comparison,  and  if  there  is  no 
valid  reason  why  this  difference  in  the  death-rates  should 
exist,  it  is  probably  true  that  all  the  deaths  in  the  city  in 
question  are  not  being  reported.  It  is  also  desirable  to 
prepare  an  ordinary  graph,  showing  the  rates  in  the  city 
under  consideration,  the  rates  in  the  United  States  Regis- 
tration Cities,  and  the  rates  in  the  cities  chosen  for  com- 
parison. In  preparing  the  graph,  the  years  covered  by 
the  statistical  analysis  can  be  used  as  abscissa  and  the 
general  death-rates  as  ordinates. 


288  VITAL  STATISTICS 

Births  and  Birth-Rates 

The  complete  reporting  of  births  is  important  for  several 
reasons.  The  first  is  that  it  enables  the  child,  later  in  life, 
to  prove  his  identity;  and  the  ability  to  do  this  may 
become  necessary  and  extremely  important  on  various 
occasions.  It  also  enables  a  community  to  determine  how 
much  of  its  increase  in  population  is  due  to  natural  causes. 
Moreover,  the  number  of  births  in  a  community  is  the 
basis  for  determining  the  infant  mortality  rate. 

It  is  customary,  during  the  health  survey,  to  determine 
the  completeness  with  which  births  are  reported.  This 
may  be  done  in  several  ways,  two  of  which  are  described, 
as  they  are  most  often  used.  The  surveyor  may  make  a 
complete  house-to-house  canvass  in  order  to  learn  of  each 
birth  that  has  occurred  in  the  community  during  the  pre- 
ceding year.  It  is  then  possible,  by  examining  the  birth- 
certificates  for  that  year,  to  determine  whether  each  birth 
has  been  reported.  This,  however,  is  a  stupendous  under- 
taking for  a  city  of  any  size;  and  the  second  method, 
which  is  described  below,  will  probably  be  more  feasible. 

In  following,  this  method,  it  is  usually  possible  to  enlist 
the  aid  of  the  agents  of  one  of  the  large  insurance  companies. 
These  men,  in  making  their  rounds,  can  obtain  information 
concerning  the  births  which  have  occurred,  during  the 
preceding  year,  in  the  families  which  they  visit.  The 
surveyor  can  then  determine,  by  referring  to  the  birth- 
records  on  file  with  the  registrar,  how  many  of  these  births 
have  been  reported.  If  only  50  per  cent  have  been  re- 
ported, and  the  reporting  of  these  births  is  representative, 
it  is  proper  to  assume  that  approximately  50  per  cent  of 
the  births  occurring  in  the  city  are  reported. 

Still  another  method  by  which  the  completeness  of  re- 
porting can  be  determined,  is  to  compare  the  local  birth- 
rates with  those  that  prevail  in  all  the  registration  cities. 


BIRTHS   AND   BIRTH-RATES 


289 


If  the  comparison  shows  that  the  birth-rate  in  the  city 
under  consideration  is  very  much  less  than  the  birth-rate 
for  all  the  registration  cities,  it  is  reasonable  to  assume  that 
all  the  births  are  not  being  reported,  unless  some  unusual 
circumstance  justifies  a  belief  in  the  accuracy  of  the  lower 
birth-rate. 

The  following  table  shows  how  the  data  regarding  births 
should  be  recorded. 

TABLE  41 

BIRTHS  AND  BIRTH-RATES  IN  "  CITY  A"  AND  OTHER  CITIES, 

1911-1920 


Popula- 
tion. 

Number  of 
births. 

Birth-rates  per  1000  population. 

Year. 

City 
A. 

U.  S.  regis- 
tration 
cities. 

Citv 
B. 

City 
C. 

City 
D. 

1911 

1912 
1913 
1914 
1915 
1916 
1917 
1918 
1919 
1920 

290 


VITAL  STATISTICS 


The  following  table  records  the  data  for  infant  mortality 
rates  in  City  A  and  compares  them  with  the  rates  for  the 
other  cities  and  for  the  United  States  Registration  Cities. 

TABLE   42 

INFANT  DEATH  SAND  INFANT  DEATH-RATES  IN  **CITY  A  " 
AND  OTHER  CITIES,  1911-1920 


City  A. 

Infant  death-rate  in 

Year. 

Births. 

Infant 
deaths. 

Infant 
death- 
rate. 

U.  S.  registra- 
tion cities. 

City 
B. 

City 
C. 

City 
D. 

1911 
1912 
1913 
1914 
1915 
1916 
1917 
1918 
1919 
1920 

The  two  tables  given  above  should  be  thoroughly  dis- 
cussed. The  data  should  be  illustrated  by  separate  graphs, 
in  which  years  are  used  as  the  abscissa  and  the  birth-rates 
or  infant  mortality  rates  as  the  ordinates. 


Statistics  for  Specific  Diseases 

The  vital  statistics  for  certain  diseases  should  next  be 
considered,  each  disease  being  studied  separately.  In  the 
final  report  on  the  survey,  it  may  be  desirable  to  precede 
the  vital  statistics  for  each  disease  with  a  few  remarks  on 
the  nature  of  the  disease,  the  methods  of  transmission, 
and  the  appropriate  prophylactic  measures.  In  each  case, 
the  table  showing  the  death-rates  from  the  disease  should 


SPECIFIC  DEATH-RATES  FROM   PNEUMONIA      291 

be  followed  by  a  graph  illustrating  the  prevailing  rates  in 
the  city  under  consideration,  in  the  United  States  Regis- 
tration Cities,  and  in  the  cities  being  used  for  comparison. 
In  this  graph  the  years  should  represent  the  abscissa  and 
the  specific  death-rates  for  the  disease  in  question,  the  ordi- 
nates.  The  diseases  that  should  be  considered,  if  statistics 
are  available,  are  pneumonia,  typhoid  fever,  malaria, 
diphtheria,  scarlet  fever,  measles,  whooping-cough,  small- 
pox and  organic  heart  diseases.  Tuberculosis  is  omitted 
here,  because  it  is  considered  in  a  special  chapter.  Other 
diseases  than  those  mentioned  may  be  included  in  the 
study,  if  they  are  found  to  be  important  causes  of  death. 

TABLE  43 

CASES,  DEATHS  AND  SPECIFIC  DEATH-RATES  FROM  PNEU- 
MONIA, IN  "  CITY  A "  AND  OTHER  CITIES,  1911-1920 

Rates  per  100,000  Population 


City  A. 

Specific  death-rates  in 

Year. 

U.  S.  reg- 
istration 
cities. 

, 

Cases 

Deaths 

Specific 

City 

City 

1     City 

reported. 

reported. 

death-rate. 

B. 

C. 

D. 

1911 

1912 

1913 

1914 

1915 

1916 

1917 

1918 

1919 

. 

1920 

292 


VITAL  STATISTICS 


TABLE  44 

CASES,   DEATHS   AND    SPECIFIC   DEATH-RATES   FROM 
TYPHOID   FEVER,   IN    "CITY   A"    AND    OTHER   CITIES, 

1911-1920 

Rates  per  100,000  Population 


City  A. 

Specific  death-rates  in 

Year. 

Cases 
reported. 

Deaths 
reported. 

Specific 
death-rate. 

U.  S.  reg- 
istration 
cities. 

City 
B. 

City 
C. 

City 
D. 

1911 
1912 
1913 
1914 
1915 
1916 
1917 
1918 
1919 
1920 

TABLE  45 

CASES,    DEATHS   AND    SPECIFIC   DEATH-RATES   FROM 
MALARIA,   IN    "CITY   A"    AND    OTHER    CITIES,  1911-1920 

Rates  per  100,000  Population 


City  A. 

Specific  death-rates  in 

Year. 

Cases 
reported. 

Deaths 
reported. 

Specific 
death-rate. 

U.  S.  reg- 
istration 
cities. 

City 
B. 

City 
C. 

City 
D. 

1911 

1912 
1913 
1914 
1915 
1916 
1917 
1918 
1919 
1920 

DIPHTHERIA   AND   SCARLET   FEVER 


293 


TABLE  46 

CASES,  DEATHS  AND  SPECIFIC  DEATH-RATES  FROM  DIPH- 
THERIA,  IN    "CITY   A"    AND    OTHER    CITIES,    1911-1920 

Rates  per  100,000  Population 


City  A. 

Specific  death-rates  in 

Year. 

Cases 
reported. 

Deaths 
reported. 

Specific 
death-rate. 

U.  S.  reg- 
istration 
cities. 

City 
B. 

City 
C. 

City 
D. 

1911 
1912 

1913 
1914 
1915 
1916 
1917 
1918 
1919 
1920 

\ 

TABLE  47 

CASES,   DEATHS   AND    SPECIFIC   DEATH-RATES   FROM 
SCARLET   FEVER,   IN    "CITY  A"    AND    OTHER   CITIES, 

1911-1920 

Rates  per  100,000  Population 


City  A. 

Specific  death-rates  in 

Year. 

Cases 
reported. 

Deaths 
reported. 

Specific 
death-rate. 

U.  S.  reg- 
istration 
cities. 

Citv 
B." 

City 
C. 

City 
D. 

1911 

1912 
1913 
1914 
1915 
1916 
1917 
1918 
1919 
1920 

294 


VITAL  STATISTICS 


TABLE  48 

CASES,   DEATHS   AND    SPECIFIC   DEATH-RATES   FROM 
MEASLES,   IN    "CITY   A"    AND    OTHER   CITIES, 

1911-1920 

Rates  per  100,000  Population 


City  A. 

Specific  death-rates  in 

Year. 

Cases 
reported. 

Deaths 
reported. 

Specific 
death-rate. 

U.  S.  reg- 
istration 
cities. 

City 
B. 

City 
C. 

City 
D. 

1911 

1912 
1913 
1914 
1915 
1916 
1917 
1918 
1919 
1920 

TABLE  49 

CASES,   DEATHS   AND    SPECIFIC   DEATH-RATES   FROM 
WHOOPING-COUGH,   IN    '^  CITY  A"   AND    OTHER 

CITIES,   1911-1920 

Rates  per  100,000  Population 


City  A. 

Specific  death-rates  in 

Year. 

Cases 
reported. 

Deaths 
reported. 

Specific 
death-rate. 

U.  S.  reg- 
istration 
cities. 

City 
B. 

City 
C. 

City 
D. 

1911 
1912 
1913 
1914 
1915 
1916 
1917 
1918 
1919 
1920 

DEATH-RATES   FROM   SMALLPOX 


295 


TABLE  50 

CASES,  DEATHS  AND  SPECIFIC  DEATH-RATES  FROM  SMALL- 
POX,  IN    "CITY  A"    AND    OTHER   CITIES,    1911-1920 
Rates  per  100,000  Population 


City  A. 

Specific  death-rates  in 

Year. 

Cases 
reported. 

Deaths 
reported. 

Specific 
death-rate. 

U.  S.  reg- 
istration 
cities. 

CUV 
B. 

City 
C. 

City 
D. 

1911 

1912 
1913 
1914 
1915 
1916 
1917 
1918 
1919 
1920 

This  table  is  of  particular  value  if  the  city  under  con- 
sideration is  one  which  has  a  considerable  amount  of 
smallpox.  In  such  cases,  it  is  desirable  to  make  compari- 
sons with  other  cities  where  smallpox  vaccination  is  com- 
pulsory, and  where  smallpox  has  been  almost  entirely 
eliminated. 


296 


VITAL  STATISTICS 


TABLE  51 

DEATHS     AND     SPECIFIC     DEATH-RATES     FROM     ORGANIC 
DISEASES    OF   THE    HEART,    IN    "CITY   A"    AND    OTHER 

CITIES,    1911-1920 

Rates  per  100,000  Population 


City  A. 

Specific  death-rates  if/f 

Year. 

Deaths 
reported. 

Specific 
death-rate. 

U.  S.  reg- 
istration 
cities. 

City  B. 

City  C. 

City  D. 

1911 

1912 
1913 
1914 
1915 
1916 
1917 
1918 
1919 
1920 

The  following  outline  of  the  chapter  on  vital  statistics 
may  be  of  aid  to  the  surveyor  in  recalling  the  various 
points  that  are  to  be  considered. 


OUTLINE    OF   CHAPTER   ON   VITAL    STATISTICS 

1.  The   need   and   value   of  having   accurate  and   complete   vital 
statistics. 

2.  Methods  of  determining  the  completeness  and  accuracy  of  the 
available  vital  statistics. 

3.  Vital  statistics  that  are  considered  in  a  pubUc  health  survey. 

a.  Population:  Race  distribution,  sex  distribution,  color  dis- 
tribution, age  distribution,  wealth,  education,  occupa- 
tion, climate. 

6.   Deaths  and  general  death-rates. 

c.  Cases  of  communicable  disease. 

d.  Births  and  birth-rates. 

e.  Infant  mortality  rates. 


OUTLINE   OF   CHAPTER  297 

/.   Specific  death-rates  from  communicable  diseases. 

Tuberculosis  —  considered  in  special  chapter 

Pneumonia 

Typhoid  Fever 

Malaria 

Diphtheria 

Scarlet  Fever 

Measles 

Whooping-Cough 

Smallpox 

Organic  Diseases  of  the  Heart 

Other  diseases,  if  particularly  prevalent. 
4.   Summary. 
6.   Recommendations. 


CHAPTER   XVTI 
ANALYSIS   OF   CITY   BUDGET 

Budget  for  Public  Health  Work,  Index  of  Public  Health 
Activities.  —  One  of  the  surest  methods  of  determining 
whether  a  community  is  adequately  protecting  the  public 
health  is  to  ascertain  how  much  money  is  being  spent  for 
health  protection,  and  how  it  is  being  spent.  By  compar- 
ing the  appropriations  for  various  municipal  activities,  one 
is  also  able  to  determine  the  relative  value  that  is  being 
placed  on  the  different  functions  of  the  municipal  govern- 
ment. If  one  should  inquire  of  any  public-spirited  citizen 
in  a  community  whether  or  not  he  thought  it  was  important 
to  protect  the  public  health,  he  would  unquestionably 
reply  in  the  affirmative.  Health,  which  is  one  of  the  prime 
essentials  to  human  happiness,  is  usually  taken  for  granted. 
Yet  the  procedure  which  is  necessary  in  order  to  obtain  a 
state  of  good  health  for  the  public  at  large  is  apparently 
known  to  comparatively  few  communities  in  the  country. 
These  are  usually  the  progressive,  enterprising,  throbbing 
centers  of  life.  They  have  learned  by  experience  that 
public  health  protection  pays. 

Adequate  Budget,  Properly  Administered,  Essential  to 
Effective  Public  Health  Work.  —  One  of  the  serious  short- 
comings of  municipal  health  protection  as  generally  prac- 
tised is  the  inadequacy  of  the  appropriation  made  for  this 
purpose.  Public  health  protection  is  a  form  of  community 
insurance;  and,  just  as  every  other  form  of  insurance  costs 
money,  so  public  health  protection  also  requires  financial 
support.  As  a  rule,  the  larger  the  budget  for  public  health 
protection    the  more  efficient  and  thorough  is  that  protec- 

298 


ADEQUATE  BUDGET  299 

tion.  This  is  not  always  true,  however,  since  a  large  budget 
administered  .by  an  untrained  and  unscrupulous  health 
officer  will  not  yield  the  desired  results.  Not  only  is  it 
necessary  to  have  an  adequate  appropriation,  but  the  con- 
trol of  the  money  must  be  placed  in  the  hands  of  experi- 
enced, trained,  honest,  and  careful  health  officials. 

Several  years  ago,  the  American  Public  Health  Associa- 
tion estimated  that  adequate  health  protection  for  a  com- 
munity could  be  obtained  with  an  appropriation  of  $3.50 
per  capita  per  year.  This  figure  was  based  on  the  activities 
of  a  modern  health  department  and  on  the  costs  of  materials 
and  labor  that  prevailed  at  that  time.  With  the  increase 
in  wages,  and  in  the  cost  of  materials,  that  followed  in  the 
wake  of  the  war,  this  figure  must  necessarily  be  increased. 
Dr.  W.  H.  Park,  of  the  New  York  City  Health  Department, 
estimated,  in  1911,  that  a  community  requires  from  $0.50 
to  $1.00  per  capita  per  year  for  adequate  health  protection. 

It  is  doubtful  whether  the  upper  limit  of  $1.00  per  capita 
per  year  is  frequently  reached;  but  it  is  reasonable  to  ex- 
pect that  the  lower  limit  of  $0.50  per  capita  per  year  should 
be  the  minimum  for  any  community.  When  a  city  is 
large,  a  per  capita  appropriation  of  $0.50  per  year  will 
enable  it  to  do  much  more  in  the  way  of  adequate  health 
protection  than  a  smaller  community  could  accomplish 
with  the  same  per  capita  appropriation.  In  order  to 
have  modern  and  satisfactory  health  protection,  smaller 
communities,  especially  those  of  which  the  population  is 
less  than  25,000,  must  provide  a  larger  per  capita  appro- 
priation than  cities  having  populations  of  50,000  and 
more.  In  some  of  the  communities  under  25,000,  it  may 
be  necessary  to  provide  an  appropriation  of  $1.00  per 
capita  per  year,  or  even  more.  With  the  growing  activities 
of  health  departments,  and  the  increased  cost  of  materials 
and  labor,  the  minimum  annual  per  capita  appropriation 
for  health   work  should  undoubtedly  be   close  to   $1.00. 


300  ANALYSIS  OF  CITY  BUDGET 

Otherwise  it  will  be  impossible  to  attract  trained  and 
experienced  health  workers  to  the  cause  of. public  health, 
or  to  conduct  the  manifold  and  ever-increasing  activities 
which  are  important  in  a  modern  health  campaign. 

Not  only  is  it  essential  to  secure  an  adequate  appropria- 
tion for  the  health  department;  it  is  equally  important  to 
know  that  the  money  is  being  spent  wisely,  and  in  those 
directions  where  it  will  do  most  good.  A  health  officer 
must  therefore  determine  the  relative  seriousness  of  the 
pressing  public  health  problems  in  his  community,  and 
decide  which  ones  will  lend  themselves  readily  to  control. 
With  this  knowledge,  he  is  in  a  position  to  determine  how 
his  appropriation  should  be  spent. 

Public  Health  Work  should  be  as  Well  Supported  as 
Other  Municipal  Activities.  —  There  are,  of  course,  numer- 
ous activities  for  which  the  municipal  funds  must  be  spent. 
In  every  case,  the  money  is  spent  either  for  the  protection 
of  life  and  property,  or  for  the  convenience,  welfare,  com- 
fort, and  education  of  the  people. 

The  municipality  is  expected  to  provide  free  education 
in  the  public  schools,  the  high  schools,  and  sometimes  even 
in  colleges  and  universities.  Every  city  also  provides  for 
health  protection,  for  protection  from  fire,  for  police  pro- 
tection, for  the  care  of  the  streets,  for  street  lighting,  for 
the  collection  and  disposal  of  refuse,  for  water-supply,  and 
for  the  collection  and  disposal  of  sewage.  All  of  these  are 
important  municipal  activities,  without  which  no  modern 
community  can  thrive  and  prosper. 

The  foundation  of  organized  society  is  an  enlightened 
citizenry,  who  appreciate  their  duty  and  obhgation  to  the 
state  and  the  nation,  as  well  as  the  need  of  pursuing  their 
own  immediate  and  personal  aims.  This  being  the  case, 
the  necessity  of  providing  free  education  cannot  be  ques- 
tioned. In  spite  of  the  large  amount  of  illiteracy  that  still 
exists  in  the  United  States,  we  can  justly  be  proud  of  our 


HEALTH   WORK   SHOULD   BE   SUPPORTED  301 

extensive  and  satisfactory  public  school  system.  It  is 
probably  true  that  the  largest  public  expenditure  in  most 
communities  in  this  country  is  for  education.  This  is  as 
it  should  be,  and  one  can  only  hope  it  may  always  continue 
to  be  so. 

There  are  also  very  large  appropriations  for  the  other 
municipal  activities.  It  is  only  when  we  compare  the 
expenditures  for  other  municipal  activities,  and  for  public 
health  protection,  that  we  find  the  latter  woefully  neg- 
lected. Twice  or  three  times  as  much  money  is  often 
spent  for  police  protection,  for  fire  protection,  for  the  care 
of  the  streets,  for  education  and  other  activities,  than  for 
protecting  the  public  health  and  preventing  disease;  and 
sometimes  the  inequality  is  even  greater  than  this.  Fre- 
quently more  money  is  spent  for  protecting  shade-trees, 
or  for  street  lighting  or  street  sprinkling  than  for  public 
health  protection.  More  money  is  usually  spent  for  main- 
taining the  public  parks  than  for  protecting  the  public 
health;  and  sometimes  more  money  is  actually  spent  in 
caring  for  the  cemeteries  than  for  preventing  disease  and 
thus  protecting  the  lives  of  the  people.  In  such  cases,  it  is 
true  that  more  money  is  being  spent  for  the  care  of  the 
dead  than  for  the  protection  of  the  health  of  the  living. 

It  is  not  because  so  much  money  is  being  spent  for  other 
municipal  activities  that  this  objection  is  raised,  but  rather 
because  so  little  is  being  spent  for  public  health  activities. 
Surely  the  protection  of  the  public  health  is  equally  as 
important  as  the  protection  of  property  by  the  police  and 
fire  departments,  or  the  maintenance  of  streets,  parks, 
cemeteries,  shade-trees  or  other  public  utilities.  For  this 
reason,  it  is  maintained  that  the  appropriation  for  pubhc 
health  work  should  at  least  equal  that  for  any  of  the  other 
municipal  activities  just  mentioned. 

Very  often  the  inadequacy  of  the  appropriation  for 
public  health  work  is  due  to  ignorance  on  the  part  of  the 


302  ANALYSIS  OF  CITY  BUDGET 

citizens.  Once  the  facts  are  brought  clearly  before  them, 
there  is  likely  to  be  a  demand  for  more  and  better  health 
protection.  The  surveyor's  purpose  in  studying  the  city 
budget  is  to  ascertain  whether  public  health  work  is  being 
adequately  supported,  and,  if  not,  to  place  the  situation 
before  the  people  in  such  a  way  as  to  cause  them  to  see  the 
facts  and  to  demand  greater  financial  support  for  this 
important  work.  The  methods  employed  in  making  the 
study  and  demonstrating  the  facts  are  described  in  detail 
in  this  chapter. 

Health  Officer  should  Seek  Adequate  Financial  Support. 
—  Public  health  work  is  inadequately  supported  in  many 
cases,  because  the  health  officer  does  not  possess  sufficient 
initiative  and  combativeness  to  fight  for  a  proper  appro- 
priation. Such  health  officers  are  either  untrained  for 
their  work  or  are  not  temperamentally  fitted  for  adminis- 
trative and  executive  positions.  They  should  be  replaced 
by  aggressive  men,  who  can  make  a  city  council  see  the 
value  of  good  health  work  and  support  it  accordingly. 

Budget  for  Public  Health  Work  should  be  Analyzed  in 
Detail.  —  In  studying  the  city  budget,  it  is  important  to 
determine  not  only  the  per  capita  appropriation  for  public 
health  work,  but  also  to  ascertain  the  activities  for  which 
the  money  is  })cing  spent,  and  the  amount  spent  for  each 
activity.  Thus,  even  if  the  appropriation  for  health  work 
is  over  $1.00  per  capita,  and  most  of  it*  is  spent  for  collect- 
ing garbage,  for  cutting  weeds,  for  inspecting  plumbing 
and  for  attending  to  nuisances,  the  actual  effort  which  is 
being  made  to  protect  the  public  health  and  to  prevent 
disease  is  exceedingly  small.  Therefore,  in  studying  the 
budget  of  the  health  department,  the  surveyor  should  dis- 
sociate those  activities  which  do  not  promote  the  public 
health  from  those  that  do.  Thus  the  appropriation  for  the 
collection  and  disposal  of  refuse  should  not  be  considered 
as   part   of   the   appropriation   for   protecting   the   public 


DATA  THAT  SHOULD  BE  OBTAINED      303 

health.  Similarly,  the  appropriation  for  maintaining 
hospitals  to  cure  disease  should  not  be  charged  against  the 
appropriation  for  preventing  disease;  and  the  expenditure 
for  other  activities  which  are  not  recognized  as  specific 
public  health  activities  should  not  be  charged  against  the 
appropriation  for  health  work. 

Data  that  should  be  Obtained  in  Studying  City  Budget. 
—  The  analysis  of  the  city  budget  involves  only  office 
work,  which  can  be  done  either  before,  after,  or  during  the 
progress  of  the  field  work.  Most  of  the  actual  data,  how- 
ever, should  be  obtained  during  the  period  of  the  survey. 
A  list  of  the  expenditures  or  appropriations  for  the  various 
municipal  activities  can  be  obtained  from  the  city  clerk, 
the  city  treasurer,  the  comptroller,  or  the  official  who  has 
charge  of  the  public  funds,  whatever  his  title  may  be. 
There  is  always  somebody  in  the  city's  employ,  who 
possesses  the  desired  information. 

The  figures  obtained  should  cover  the  preceding  three 
years,  or  a  longer  period.  The  surveyor  should  procure 
a  memorandum  of  the  total  appropriation  of  the  city,  and 
also  an  itemized  account  of  the  expenses  of  the  health 
department.  Having  a  list  of  expenditures  for  each  de- 
partment for  at  least  three  consecutive  years,  and  knowing 
the  population  in  each  year  under  consideration,  he  will 
be  able  to  construct  a  table  showing  the  per  capita  expen- 
diture for  each  activity.  This  figure  is  really  of  greater 
value  than  the  total  expenditure  for  each  municipal  activity, 
and  can  be  used  to  make  comparisons  with  expenditures  for 
similar  activities  in  other  cities. 

The  following  tables  illustrate  the  manner  in  which  the 
information  should  be  recorded.  The  data  are  those 
obtained  for  Oklahoma  City,  which,  in  1920,  had  a  popu- 
lation of  approximately  100,000. 


304 


ANALYSIS  OF  CITY  BUDGET 


TABLE  52 

EXPENDITURES   FOR   VARIOUS   MUNICIPAL  ACTIVITIES, 

OKLAHOMA    CITY,    OKLA. 


Department. 


Street  Department 

Sidewalk  Department 

Street  Lighting 

Engineering  and  Sewer  Dept. 

Building  Inspection  Dept 

Park  Department 

Water  Department 

Carnegie  Library 

Inspection   of   weights    and 

Measures 

Police      Department       and 

Alarm  System 

Fire  Department  and  Alarm 

System 

Health  Department 

Garbage  Department 

Detention  Hospital 

Maternity  Home 

Public  School  Education.  .  .  . 


1915. 


$48,042.74 

2,521.66 

33,805.63 

14,441.27 

4,174.36 

19,556.85 

116,858.85 

6,724.22 

1,269.99 

76,479.19 

94,045.97 

18,216.16 

22,688.52 

8,918.05 

1,445.16 

340,277.00 


1916. 


$48,836.32 

2,310.06 

37,564.19 

16,810.82 

3,857.66 

19,976.36 

123,157.82 

6,619.85 

1,263.25 

77,377.19 

103,880.88 

16,642.53 

23,938.80 

7,606.56 

1,641.26 

352,477.00 


1917. 


$56,284.47 

1,308.10 

33,146.67 

20,138.38 

4,443.31 

27,556.22 

187,610.81 

6,960.09 

1,350.10 

76,439.07 

99,136.48 

19,728.35 

22,292.36 

8,002.76 

1,876.62 

390,755.00 


TABLE  53 
PER   CAPITA   EXPENDITURES   FOR   MUNICIPAL   ACTIVITIES, 

OKLAHOMA   CITY,   OKLA. 


Department. 


Street  Department 

Engineering  and  Sewer  Department.. . 

Building  Inspection  Department 

Detention  Hospital 

Park  Department 

Water  Department 

Sidewalk  Department 

Carnegie  Library 

Garbage  Department 

Health  and  City  Chemist  Department 

Maternity  Home 

Street  Lighting 

In.spection  of  Weights  and  Measures.  . 
Police  Department  and  Alarm  System 
Fire  Department  and  Alarm  System .  . 
Public  School  Education 


1915. 

1916. 

1917. 

$0.54 

$0.53 

$0.57 

0.16 

0.18 

0.21 

0.05 

0.04 

0.05 

0.10 

0.08 

0.08 

0.22 

0.22 

0.28 

1.32 

1.33 

1,92 

0.03 

0.02 

0.01 

0.08 

0.07 

0.07 

0.26 

0.26 

0.23 

0.21 

0.18 

0.20 

0.016 

0.018 

0,019 

0.38 

0.40 

0.34 

0.014 

0.014 

0.014 

0.86 

0.83 

0.78 

1.16 

1.12 

1.01 

3  89 

3.80 

4.00 

PER   CAPITA  APPROPRIATION  305 

Per  Capita  Appropriation  for  Public  Health  Work  should 
be  Compared  with  Similar  Appropriations  in  Other  Cities. 

—  Another  method  of  studying  the  city  budget  is  to  com- 
pare the  per  capita  expenditure  for  health  work  in  the  city 
under  consideration,  with  that  made  by  other  cities.  The 
cities  chosen  for  comparison  should  have  approximately  the 
same  population  and  should  preferably  be  located  in  the 
same  section  of  the  country.  Where  this  is  not  possible, 
comparison  should  be  with  cities  having  approximately  the 
same  population  and  located  in  other  parts  of  the  country. 

The  figures  for  this  comparison  can  be  obtained  either 
from  reports  issued  by  the  several  cities,  by  personal  com- 
munication with  responsible  city  officials  in  these  cities 
or   from   the    Reports   on   Financial   Statistics   of   Cities 
published  by  the   United   States  Bureau  of  Census.     In 
these  reports,  the  per  capita  expenditure  for  each  city  is 
given  in  a  column  headed  ''Health  Conservation."     The 
cities  are  divided  in  groups,  according  to  their  population 
so  that  it  is  a  simple  matter  to  get  the  statistics  for  all  the 
cities  in  a  given  population  group. 

It  will  be  unnecessary  for  the  surveyor  to  quote  the  statis- 
tics for  all  the  cities  given,  if  their  number  is  very  large. 
In  such  a  case,  he  has  a  choice  and  can  select  cities  which 
are  in  the  same  geographical  area  as  the  one  under  con- 
sideration. It  is  desirable,  however,  to  include  several 
cities  from  other  sections  of  the  country,  in  order  to  make 
the  comparison  nation-wide,  and  not  merely  sectional. 

The  surveyor  should  also  determine  what  percentage  of  all 
the  cities  in  the  same  population  group  have  a  per  capita 
health  expenditure  greater  than  that  of  the  city  in  question. 
The  statistics  for  several  years  should  be  obtained  and 
studied  in  order  to  make  the  conclusions  more  valuable. 

The  term  ''health  conservation,"  as  used  in  these  reports, 
includes  such  items  as  health  department  administration, 
vital  statistics,  prevention  and  treatment  of  communicable 


306 


ANALYSIS  OF  CITY  BUDGET 


diseases,  conservation  of  child  life,  and  food  regulation  and 
inspection.  It  is  therefore  a  term  which  applies  to  all 
those  activities  that  aim  to  prevent  disease.  The  per 
capita  expenditure  for  health  conservation,  as  given  in 
these  reports,  is,  therefore,  an  index  of  the  community's 
efforts  to  conserve  life  and  prevent  disease. 

A  typical  table,  compiled  from  these  data  for  Oklahoma 
City,  is  reproduced  below. 


TABLE  54 

SOME  CITIES  HAVING  POPULATIONS  OF  50,000  TO   100,000, 
WHICH   ARE   SPENDING   MORE,   PER   CAPITA,   FOR 
HEALTH   CONSERVATION   THAN    OKLAHOMA   CITY 


City. 


Lawrence,  Mass 

Yonkers,  N.  Y 

Schenectady,  N.  Y. .  . 

DuUith,  Minn 

Norfolk,  Va 

Elizabeth,  N.  J 

Somerville,  Mass 

Waterbury,  Conn. .  .  . 

St.  Joseph,  Mo 

Utica,  N.  Y 

Troy,  N.  Y 

Manchester,  N.  H.. .  . 

Hoboken,  N.J 

Erie,  Penn 

Jacksonville,  Fla 

Passaic,  N.  J 

Savannah,  Ga 

Brockton,  Mass 

Sacramento,  Cal 

Holyoke,  Mass 

El  Paso,  Texas 

Charleston,  S.  C 

Chattanooga,  Tenn. . . 

Mobile,  Ala 

Atlantic  City,  N.  J.. . 
New  Britain,  Conn.. . 

San  Diego,  Cal 

Maiden,  Mass 

Oklahoma  City,  Okla. 


1916. 


$0.54 

$0.59 

0.88 

0.96 

0.30 

0.48 

0.37 

0.35 

0.37 

0.44 

0.31 

0.38 

0.51 

0.47 

0.27 

0.25 

0.20 

0.23 

0.20 

0.18 

0.28 

0.36 

0.23 

0.26 

0.27 

0.30 

0.25 

0.21 

0.28 

0.32 

0.26 

0.26 

0.39 

0.39 

0  43 

0.51 

0.38 

0.33 

0.62 

1.74 

0.30 

0.30 

0.31 

0.29 

0.31 

0.18 

0.41 

0.26 

0.33 

0.52 

0.33 

0.32 

0.81 

0.86 

0.53 

0.54 

0.19 

0.19 

1917. 


RESULTS  SHOULD  BE   ILLUSTRATED 


307 


Results  of  Study  should  be  Illustrated  Graphically.  —  It 

is  always  desirable  to  illustrate  figures  in  a  graphical  way, 
as  this  aids  the  reader  to  understand  them  more  readily. 
A  chart  should  therefore  be  arranged  to  bring  out  the  fact 
that  the  city  under  consideration  is  spending  less,  per 
capita,  for  health  conservation  than  other  cities  of  the 
same  size.  To  illustrate  this  point,  the  following  chart  is 
reproduced  from  the  Oklahoma  City  Public  Health  Survey. 
The  figures  were  obtained  from  Table  No.  56,  in  the  report 
just  mentioned. 

PER    CAPITA    APPROPRIATION    FOR    HEALTH    CONSERVATION, 

1917,   CITIES    50,000-100,000. 


Yonkers.    N.    Y.     .96 


San    Diego,     Cal.,     .86 


Lawrence,  Mass.     .59 


Schenectady,  N.  Y.     .48 


Norfolk.  Va.     .44 


Savannah,    Ga.     .39 


El  Paso.  Texas.     .30 


Mobile.  Ala.     .26 


St.  Joseph.  Mo.     .23 


OKLAHOMA 
CITY.   OKLA.     .19 


Chatlanooga.   Tenn.     .18 


Fig.  95. 


308 


ANALYSIS  OF  CITY  BUDGET 


Comparison  of  Appropriations  for  Public  Health  Activi- 
ties, for  Cities  in  the  Same  State,  should  also  be  Made.  — 
Another  instructive  and  profitable  method  of  analyzing  the 
city  budget  is  to  compare  the  percentage  expenditure  for 
each  municipal  activity  with  similar  expenditures  for  other 
cities,  of  approximately  the  same  size,  in  the  same  state. 
Very  often  the  rivalry  between  neighboring  cities  is  so  great 
that  each  is  jealous  of  the  progress  the  other  makes.  This 
fact  can  sometimes  be  capitalized  to  obtain  a  larger  appro- 
priation for  pul)lic  health  work  in  the  city  under  considera- 
tion. This  point  is  illustrated  by  the  following  table, 
compiled  from  the  Bureau  of  Census  reports  referred  to 

above. 

TABLE  55 

PER  CENT  DISTRIBUTION  OF  THE  EXPENSES  FOR  THE  GEN- 
ERAL   MUNICIPAL    ACTIVITIES    OF    OKLAHOMA    CITY, 
MUSKOGEE,   AND   TULSA,    OKLA.,   IN    1917 


General  Government 

Legislative 

Executive 

Judicial 

Elections  and  General  Government 

Buildings 

Protection  to  Person  and  Property 

Police  Department 

Fire  Department 

All  Other 

Conservation  of  Health 

Sanitation  or  Promotion  of  Cleanliness . . 
Highways 

General  Expense 

Repair  and  Construction  for  Com- 
pensation  

Charities,  Hospitals  and  Correction 

Education 

Schools 

Libraries 

Recreation 

Miscellaneous 

General 


Oklahoma 
City. 

Muskogee. 

"7.5" 

'll'2" 

0.3 

0.3 

1.6 

0.4 

8.1 

8.0 

11.9 

11.1 

0.8 

0.3 

2.1 

0.8 

6.3 

2.4 

8.5 

9.8 

0.7 

0.7 

2.4 

5.0 

45.4 

42.1 

0.8 

1.7 

3.2 

4.8 

0.05 

0.05 

0.2 

1 

1.3 

Tulsa. 


12.6 

0.3 

1.2 

9.6 
9.5 
1.3 
2.6 
3.6 

7.6 

0.8 
2  5 

39.7 
1.4 
5.3 
0.05 
2.0 


OUTLINE  OF  CHAPTER  309 


OUTLINE   OF   CHAPTER   ON   ANALYSIS   OF   CITY  BUDGET 

• 

1.  Need  of  studying  appropriations  for  various  municipal  activities, 
to  determine  whether  pubhc  health  work  is  being  adequately  supported. 

2.  Adequate  appropriation  necessary  for  public  health  work. 
Effect  of  honest  and  trained  health  officer  on  value  received  from  avail- 
able funds.  Probably  $0.50  to  $L00  per  capita  per  year  required  for 
efficient  health  work.  Smaller  cities  require  a  larger  per  capita  appro- 
priation than  larger  ones. 

3.  Comparison  of  per  capita  appropriations  for  public  health  work 
with  those  for  education,  fire  protection,  pohce  protection,  care  of 
streets,  care  of  shade-trees,  care  of  parks,  water  department  and  other 
municipal  activities. 

4.  Comparison  of  appropriations  for  "  health  conservation  "  with 
similar  appropriations  for  cities  of  the  same  size  in  other  parts  of  the 
country. 

6.  Comparison  of  the  city  budget  for  other  cities,  of  approximately 
the  same  size,  in  the  same  state. 

6.  Summary. 

7.  Recommendations. 


CHAPTER   XVIII 
THE   PREPARATION    OF   THE   REPORT 

Final  Report  should  be  Complete  and  Well-Prepared.  — 

The  preparation  of  the  final  report  is  one  of  the  most 
important  tasks  connected  with  the  survey.  The  people's 
final  judgment  of  the  thoroughness  and  value  of  the  survey 
will  be  based  on  the  report,  which  will  give  them  their 
first  opportunity  to  know  definitely  what  the  survey  has 
attempted  and  accompHshed.  Even  the  members  of  the 
central  committee  will  not  become  fully  informed  as  to 
the  scope  and  results  of  the  work  which  they  have  fostered, 
until  the  report  is  published.  It  is  therefore  exceedingly 
important  that  this  report  should  be  comprehensive,  that 
it  should  contain  all  the  data  collected  during  the  survey, 
and  that  the  results  should  be  accurately  and  intelligently 
interpreted.  The  report  should  contain  the  results  of  all 
the  laboratory  examinations,  inspections,  score-card  ratings, 
photographs  and  charts.  The  story  should  be  told  clearly 
and  in  simple  language;  and  considerable  attention  should 
be  devoted  to  making  the  report  attractive. 

Preparation  of  Final  Report  is  a  Long  and  Tedious  Task. 
—  The  writing  of  a  surve}^  report  is  a  long,  tedious,  and 
trying  undertaking.  The  author  has  found  it  necessary 
to  rewrite  a  report  three  times,  before  it  could  be  con- 
sidered ready  for  the  printer.  A  comprehensive  report, 
like  those  published  for  the  Oklahoma  Public  Health  Sur- 
veys, usually  requires  at  least  one  month  of  full  time,  for 
its  completion.  This  allowance  includes  the  preparation 
of  all  tables,  the  revision  of  the  first  and  second  drafts,  the 
preparation  of  all  charts  for  final  printing,  and  the  descrip- 

310 


SUMMARY  AND  A  SET  OF  RECOMMENDATIONS      311 

tion  of  the  photographs  which  are  to  accompany  the 
report. 

In  order  to  be  able  to  write  the  best  possible  report,  the 
investigator  should  have  uninterrupted  quiet,  with  ade- 
quate stenographic  assistance.  A  stenographer  who  is 
familiar  with  the  terminology  of  public  health  work,  and 
who  can  transcribe  her  notes  accurately  and  fully,  will  save 
the  surveyor  many  anxious  and  disturbing  moments. 

The  first  draft  should  be  written  in  duplicate,  on  cheap 
paper.  As  each  chapter  is  completed,  the  pages  should  be 
pinned  together  and  placed  in  a  special  folder,  properly 
marked.  The  marking  may  be  as  follows:  —  ''Oklahoma 
City  Public  Health  Survey  —  First  Draft."  As  each  chap- 
ter is  read,  corrected  and  revised,  it  should  be  placed  in  a 
second  folder  marked,  "Oklahoma  City  Public  Health 
Survey  —  First  Draft,  Corrected  and  Revised."  As  soon 
as  possible,  this  should  be  rewritten,  the  result  being  the 
second  draft,  which  should  embody  all  the  corrections, 
revisions  and  rearrangements  made  in  the  first  draft. 
Attention  should  be  given  to  proper  paragraphing,  punc- 
tuation, grammar  and  any  other  points  which  will  tend  to 
make  the  report  as  finished  a  product  as  possible.  The 
several  chapters  should  then  be  placed  in  a  special  folder 
bearing  the  name  of  the  survey,  with  the  additional  infor- 
mation that  they  belong  to  the  second  draft.  Additional 
corrections  and  revisions  may  be  made  at  this  point.  The 
second  draft  may  be  written  on  good  paper,  and  should 
also  be  prepared  in  duplicate. 

Each  Chapter  should  Include  a  Summary  and  a  Set  of 
Recommendations.  —  Each  chapter  should  be  corrected 
separately,  and,  at  the  end  of  each,  a  summary  and  a  set 
of  recommendations  should  be  given.  The  value  of  the 
summary  and  of  the  itemized  recommendations  will  be 
pointed  out  later.  In  order  to  prepare  them,  it  has  been 
found  advisable,   while  a  chapter  is  being  corrected,   to 


312        PREPARATION  OF  THE  REPORT 

make  memoranda  of  all  the  important  points  touched 
upon  and  of  the  recommendations  suggested  by  them. 
Immediately  after  the  chapter  has  been  read,  and  while  all 
the  facts  are  fresh  in  the  mind,  the  summary  and  recom- 
mendations should  be  written.  Comparatively  few  people 
will  have  time  to  read  the  complete  report;  but  almost 
all  who  are  interested  in  the  survey  will  be  sure  to  read  the 
summary  and  recommendations.  It  is  therefore  exceed- 
ingly important  that  the  summary  be  complete,  well- 
written  and  accurate.  Inasmuch  as  these  portions  of  the 
report  are  not  very  long  and  should  be  prepared  with  the 
greatest  care,  it  will  probably  be  desirable  to  write  them 
in  long  hand. 

Almost  everybody  who  receives  a  copy  of  the  report  will 
be  interested  in  the  recommendations.  These  should 
appear  immediately  after  the  summary  of  the  chapter  to 
which  they  belong  and  should  point  out  the  important 
improvements  that  are  necessary,  each  suggestion  being 
embodied  in  a  separate  paragraph,  and  numbered.  It  is 
unwise  to  enumerate  all  the  minor  recommendations  that 
could  be  made;  only  those  that  are  extremely  important 
and  that  have  a  direct  bearing  on  the  public  health  should 
be  listed.  The  investigator  will  have  to  decide  which 
recommendations  are  to  be  enumerated  at  the  end  of  each 
chapter. 

Third  Draft  should  be  Perfect.  —  After  a  chapter  has 
been  corrected,  and  the  summary  and  recommendations 
written,  it  should  be  placed  in  the  special  folder  provided 
for  the  corrected  second  draft.  Th(^  third  draft,  which 
should  be  written  as  soon  as  possible,  presents  the  text 
of  the  report  in  its  final  form.  When  it  has  been  reread, 
and  all  necessary  changes  made,  the  report  is  ready  for  the 
printer  and  should  be  placed  in  a  special  folder,  marked 
with  the  name  of  the  survey,  and  the  words  ''Final  Draft." 
The  chapter  headings  and  sub-heads  should  be  inserted; 


MUST   BE   FAMILIAR  WITH   DATA  313 

and  the  chapters  should  be  arranged  in  the  order  in  which 
they  are  to  appear  in  the  final  printed  report. 

Preface ;  Foreword ;  Introduction.  —  It  is  also  desirable 
to  include  a  preface,  a  foreword  and  an  introduction.  The 
preface  may  be  prepared  by  the  leader  of  the  organization 
sponsoring  the  survey.  The  foreword  should  tell  very 
briefly  of  the  community  organization  for  the  survey,  and 
should  describe  any  special  problem  which  was  encountered. 
Acknowledgment  should  also  be  made  to  all  those  who  have 
aided  in  the  work.  'The  introduction  should  give  general 
information  about  the  city,  including  its  area,  population, 
location,  elevation,  temperature  and  other  cHmatic  condi- 
tions, the  nativity  of  the  population,  the  industries,  recrea- 
tional facilities  and  any  other  facts  of  general  interest 
which  are  not  covered  in  the  body  of  the  report,  or  a  sepa- 
rate chapter. 

Surveyor    must    be    Thoroughly    Familiar    with    Data 
before  Writing  the  Report.  —  Before  beginning  to  dictate 
the  report,  the  writer  should  become  thoroughly  familiar 
with  all  the  facts  involved.     It  is  advisable  to  assemble 
and  review  all  the  data  on  a  given  subject,  and  then  dictate 
or  write  the  chapter  on  that  subject,  before  passing  on  to 
the  next.     In  this  way  the  mind  is  not  so  likely  to  become 
confused   by  the   number  and  variety  of  subjects  under 
consideration.     All  tables,  graphs  and  photographs  for  the 
chapter  which   is  to  be  written  should  also  be  at  hand. 
Before  beginning  the  dictation,  the  surveyor  should  out- 
line the  chapter  and  enumerate  the  points  which  are  to  be  dis- 
cussed.    In  this  way,  he  will  be  sure  to  include  all  the  facts 
and  will  be  more  likely  to  present  them  in  logical  seouence. 
The  original  data,  as  collected,  will  not  be  arranged  in 
the  logical  sequence  in  which  they  should  appear  in  the 
final  report.     It  will  be  necessary,  therefore,  for  the  sur- 
veyor to  read  his  original  notes  carefully,  and  to  select  all 
the  facts  that  are  to  go  in  a  certain  chapter.     For  instance, 


314        PREPARATION  OF  THE  REPORT 

all  the  facts  relating  to  water-supply  may  be  marked 
'Svater-supply,"  and  all  those  relating  to  the  control  of 
tuberculosis  may  be  similarly  marked  and  identified. 
Professor  Whipple,  whose  article  is  quoted  below,  suggests 
that  every  subject  be  given  a  number.  Thus,  according  to 
his  plan,  all  data  referring  to  water-supply  should  be 
marked  V,  1,  and  all  those  referring  to  hospitals  and  dis- 
pensaries should  be  marked  VI,  3.  Then  all  the  notes 
may  be  grouped  according  to  their  markings,  and  all  the 
data  will  be  found  to  be  properly  assembled.  Each  subject 
considered  under  sanitation  is  subdivided,  and  each  sub- 
division is  given  a  special  number.  After  studying  the 
notes  carefully,  the  surveyor  should  be  able  to  write  a 
comprehensive  and  complete  report  on  the  subject,  pre- 
senting all  the  facts  in  logical  order. 

The  outline  which  is  given  below  has  been  arranged  by 
Professor  G.  C.  Whipple,  and  appeared  in  the  International 
Journal  of  Public  Health,  for  July  1920. 


OUTLINE    OF    TOPICS    CONSIDERED    IN    A   PUBLIC    HEALTH 
SURVEY  WITH  INDEX  NUMBERS  FOR  EACH  SUBJECT 

Prepared  by  Professor  G.  C.  Whipple 

CHAPTER   I.     The  Locality. 

1.  Geography.     (Name    or    names;      latitude    and    longitude; 

political    boundaries    and    subdivisions;     area;     distances; 
railroad  or  steamboat  connections,  etc.) 

2.  Maps.     (Duplicate  copies  of  general  and  local  maps.) 

3.  Topography.     (Description   of   hills,    valleys,    plains,    slopes, 
contours,  elevations,  etc.) 

4.  Geology.     (Top-soil,  sub-soil,   rock  foundations,  special  fea- 

tures, etc.) 

5.  Hydrography.     (Rivers,    laker,    marches;     stream-flow    and 

variations,  tidal  phenomena,  etc.) 

6.  Vegetation.     (Forests,  plants,  water-weeds,  alga?,  etc.) 

7.  Animal  life.     (Domestic  animals,   wild  animals,   snakes,   in- 

sects, etc.) 


OUTLINE  OF  TOPICS  315 

8.  Use  of  land.     (Agriculture,  vineyards,  grazing,  etc.) 

9.  Use  of  water.     (Dams,  mills,  canals,  irrigation,  etc.) 

10.    Public  works  and  utilities.     (Streets,  parks,  street  lighting, 
gas,  electricity,  etc.) 

CHAPTER  II.    The  Climate. 

1.  Temperature.     (Typical  record  arranged  by   months,   aver- 

age,   maximum,    minimum,    etc.,    depending    on    available 
information.) 

2.  Humidity.     (Typical  record  arranged  by  months,   average, 

maximum,  minimum,  etc.,  depending  on  available  informa- 
tion.) 

3.  Rainfall.     (All  available  annual  records;    seasonal  distribu- 

tion;  typical  daily  records  for  one  year;   maximum  rates  of 
rainfall,  etc.) 

4.  Snow,  ice,  fog,  etc.     (General  statement.) 

5.  Winds.     (Records  of  wind-velocity,  or  a  general  statement  of 

seasonal  conditions.) , 

6.  Sunshine.     (General  statement.) 

CHAPTER  III.    The  People. 

1.  Population.     (Number   of   people;     census   records  for   past 

years;   methods  of  estimation;   subdivisions  by  area,  etc.) 

2.  Classification  of  population.     (By  sex  and  age-groups,  etc.) 

3.  Density  of  population.     (By  subdivisions  of  area;  by  houses, 

by  families,  etc.) 

4.  Race  and  nationality.     (Statistics  or  general  statement.) 

5.  Religion.     (Statistics  or  general  statement.) 

6.  Education.     (Literary;   schooling;   newspapers,  etc.) 

7.  Government.     (A  comprehensive  description  of  governmental 

framework.) 

8.  Industries  and  occupations.     (General  statement.) 

9.  Economic  statement.     (Ownership  of  land  and  homes;   hours 

of  employment;  wages;  pauperism,  etc.) 

10.  Women  and  children  in  industry.     (General  statement.) 

CHAPTER   IV.     Vital  Statistics. 

1.  Methods  of  collecting  data. 

2.  Births  and  birth-rates.     (For  as  many  years  as  possible.) 

3.  Deaths  and  death-rates.     (For  as  many  years  as  possible.) 

4.  Infant  mortahty. 


316        PREPARATION  OF  THE  REPORT 

5.  Deaths  classified  by  causes,  but  with  special  reference  to  the 

following:  —  Typhoid  fever;  Typhus  exanthemata;  relaps- 
ing fever;  Malarial  fever;  Plague,  Asiatic  cholera;  Measles; 
Whooping-cough;  Scarlet  fever;  Diphtheria  and  Croup; 
Smallpox;  Dysentery,  bacillary;  Dysentery,  amebic;  Pul- 
monary Tuberculosis;  Other  Tuberculosis;  Bronchitis; 
Broncho-pneumonia;  Lobar  pneumonia;  Influenza;  Infant 
Diarrhea;  Acute  poliomyehtis;  Cerebrospinal  meningitis; 
Rickets. 

6.  Classification  of  deaths  from  each  cause  by  age,  season,  etc. 

7.  Statement  as  to  unusual  diseases  such  as  Malta  fever,  Yellow 

fever,  leprosy,  hookworm  disease,  ophthalmia,  goitre. 

8.  Notable  outbreaks  of  disease. 

9.  Records  of  cases  of  certain  diseases  (correspondmg  to  those  of 

§  5  and  §  7). 
10.    Visits  of  physicians  (for  certain  diseases,  §  5  and  §  7). 

CHAPTER  V.     Sanitation. 

1.  Water  supply.     (The  subdivisions  of  this  and  the  other  sec- 

tions of  this  chapter  are  given  in  detail  below.) 

2.  Drainage   and   Sewerage.     (Includes   disposal   of   rain-water, 

house  sewage,  sullage  waters  and  other  liquid  wastes.) 

3.  Disposal  of  human  excreta  (by  methods  other  than  sewerage). 

4.  Use  and  disposal  of  animal  manure. 

5.  Refuse    disposal.     (Scavenging,    disposal    of    garbage,    ashes, 

rubbish,  etc.) 

6.  Disposal  of  the  dead. 

7.  Sanitation  of  buildings.   (Dwelling  houses,  schools,  factories, 

hotels,  etc.) 

8.  Sanitation  of  the  air.     (Smoke,  fumes,  odors,  etc.) 

9.  Control  of  animals  and  insects.     (Rats,  flies,  mosquitoes,  etc.) 

10.  Food  sanitation.     (Milk,  etc.) 

11.  Sanitation  of  transportation  facilities. 

12.  Miscellaneous  sanitary  matters.     (Baths,  laundries,  etc.) 

CHAPTER   VI.   Health  Administration. 

1.  Physicians.     (Number,  education,  facilities,  methods  of  con- 

ducting professional  work.) 

2.  Nurses     and     mid  wives.       (Number,     educational     facilities, 

etc.) 

3.  Hospitals,  dispensaries,  etc. 


DETAILED   INDEX   OF   TOPICS  317 

4.  Organization  of  Public  Health  Authorities.     (PoHtical  rela- 

tions;   powers  and  duties;    organization;    work  done;    efl&- 
ciency;   appropriations;   laboratory  facilities,  etc.) 

5.  Pubhc  welfare  woi 

6.  Pubhc  charities. 

7.  Laws  relating  to  public  health  matters  —  especially  sanitation. 

8.  Unofficial   health   and  welfare  organizations.     (Names,  work 

done,  how  supported,  etc.) 

CHAPTER  VII.     Special  Survey  Information. 

1.  Names  and  addresses.     (Officials;  persons  giving  information 

persons  interested.) 

2.  References  to  reports  and  printed  matter  from  which  informa- 

tion was  taken. 

3.  Itinerary  of  the  survey. 

4.  Reports  made  to  the  oflSce. 

5.  Expense  accounts. 

DETAILED    INDEX   OF   TOPICS,    CHAPTER  V, 

"SANITATION" 

Section  1.     Water-Supply 
V  1.0    Any  topic  under  water-supply  awaiting  classification. 

1.1  History  and  development. 

1.2  Ownership,  pubhc,  private,  etc. 

1.3  Source  of  supply,  lakes,  rivers,  reservoirs,  springs,  wells,  etc. 

1.4  Description  of  works. 

1.5  Capacity  of  supply,  present  and  potential;  adequacy. 

1.6  Quality  of  the  supply  —  analyses,  inspection,  etc. 

1.7  Purification  of  water,  methods,  efficiency. 

1.8  Distribution  of  water  — public,  private,  fire  protection. 

1.9  Consumption  of  water,  average  daily,  variations. 
1  10  Financial  matters,  cost  of  works,  water  rates,  etc. 

1.11  Communal  supplies,  i.e.,  supplies  not  distributed,  used  by  many 

people. 

1.12  Individual  supphes,  wells,  methods  of  procuring  water 

1.13  Recommendation. 

Section  2.     Drainage  and  Sewerage 

V  2.0     Topic  awaiting  classification. 

2.1     Surface  drainage;  street  drainage;  sullage  waters. 


318        PREPARATION  OF  THE  REPORT 

2.2  Land-drainage,  ditches,  tile-drains,  etc. 

2.3  History  of  sewerage  works. 

2.4  Ownership  of  works. 

2.5  Description  of  works. 

2.6  Capacity  of  works. 

2.7  Adequacy  of  works.     Nuisances  from  lack  of  sewerage. 

2.8  Sewage  treatment. 

2.9  Liquid  trades  wastes. 

2.10  Ultimate  disposal:  —  pollution  of  streams,  lakes,  harbors,  etc. 

2.11  Utilization. 

2.12  Financial  matters;  cost  of  works,  methods  of  support. 

2.13  Recommendations. 

Section  3.     Disposal  of  Human  Excreta 

V  3.0     Topic  awaiting  classification. 

3.1  Temporary  receptacles;  cans,  pails,  etc. 

3.2  Surface  privy  system. 

3.3  Pit  privy  system. 

3.4  Vault  system. 

3.5  Cesspool  system. 

3.6  Septic  tank  system. 

3.7  Chemical  closets. 

3.8  Use  of  seats,  floor-openings,  etc. 

3.9  UtiUzation  of  excreta  as  fertilizer. 

3.10  Treatment  of  excreta. 

3.11  Tinettes  filtrantes. 

Section  4.     Use  and  Disposal  of  Animal  Manure 

V  4.0     Topic  awaiting  classification. 

4.1  Quantity. 

4.2  Animals  —  horses,  cows,  sheep,  pigs,  hens,  etc. 

4.3  Storage. 

4.4  Methods  of  handling. 

4.5  Nuisances. 

Section  5.    Refuse  Disposal 

V  5.0     Topics  awaiting  classification. 

5.1  Domestic  receptacles  for  refuse. 

5.2  Collection  of  refuse. 

5.3  Disposal  of  garV)age. 

5.4  Disposal  of  ashes  (cinders). 


DETAILED   INDEX  OF   TOPICS  319 

5.5  Disposal  of  rubbish. 

5.6  Disposal  of  street-sweepings. 

5.7  Disposal  of  dead  animals. 

5.8  Incineration  of  refuse. 

5.9  Reduction  of  garbage. 

5.10  Utilization. 

5.11  Nuisances. 

Section  6.     Disposal  of  Dead 

V  6.0     Topic  awaiting  classification. 

6.1  Burial. 

6.2  Cremation. 

6.3  Other  methods. 

6.4  Laws. 

6.5  Religious  customs. 

Section  7.     Sanitation  of  Buildings 

V  7.0     Topic  awaiting  classification. 

7.1  Plan  of  city,  location  of  houses,  adjacency  of  buildings. 

7.2  Building  restrictions,  legal  matters. 

7.3  Occupancy  of  buildings,  volume,  area,  subdivisions. 

7.4  Light,  windows,  artificial  illumination. 

7.5  Heating,  methods,  availability  of  fuel. 

7.6  Ventilation;  doors,  windows,  etc.     Habits  of  people. 

7.7  Plumbing. 

7.8  General  cleanliness,  habits  of  people,  soap. 

7.9  Sanitation  of  schools. 

7.10  Sanitation  of  factories. 

7.11  Protection  of  laborers  against  accident. 

7.12  Protection  of  laborers  against  industrial  poisons. 

Section  8.     Air   Sanitation 

V  8.0     Topic  awaiting  classification. 

8.1  Dust. 

8.2  Smoke. 

8.3  Odors  from  nuisances. 

Section  9.     Animal  and  Insect  Pests 

V  9.0     Topic  awaiting  distribution. 

9.1  Rats. 

9.2  Flies. 


320  PREPARATION  OF  THE  REPORT 

9.3  Mosquitoes. 

9.4  Lice. 

9.5  Fleas. 

9.6  Other  insects.  , 

Section  10.    Food  Sanitation 

V  10.0     Topic  awaiting  classification. 

10.1  General  description  of  major  food  supplies. 

10.2  Milk-supply:  quantity,  methods  of  production  and  distribu- 

tion. 

10.3  Milk-supply,  quality. 

10.4  Sanitation  of  abattoirs. 

10.5  Sanitation  of  markets. 

10.6  Sanitation  of  fish-supply. 

10.7  Sanitation  of  shell-fish. 

10.8  Protection  of  foods  on  sale. 

10.9  Sanitation  of  restaurants. 

10.10  Canned  goods. 

Section  11.     Sanitation  of  Transportation  Facilities 

V  11.0     Topic  awaiting  classification. 

11.1  Steamships. 

11.2  Railroad  cars. 

11.3  Railroad  stations. 

Section  12.     Miscellaneous 

V  12.0     Topic  awaiting  classification. 

12.1  Public  baths. 

12.2  Laundries. 

12.3  Public  comfort  stations. 

Past  Accomplishments  should  not  be  Ignored  in  the 
Report.  —  It  is  advisable  to  include,  in  each  chapter,  some 
appropriate  reference  to  conditions  existing  in  the  past. 
Thus,  in  the  chapter  dealing  with  the  water-supply,  a  brief 
sketch  of  the  development  of  the  water-supply  may  be 
given,  and  wherever  possible,  the  historical  side  of  each 
subject  should  receive  some  attention.  Moreover,  before 
beginning  to  write  a  chapter,  the  surveyor  must  become 


PROOF  SHOULD  BE  CAREFULLY  READ     321 

thoroughly  famihar  with  all  previous  reports  made  to  the 
community  on  the  same  subject. 

While  the  stenographer  is  transcribing  her  notes,  the 
writer  may  be  preparing  the  tables  for  some  other  chapter, 
and  studying  tha  subject-matter  which  is  to  accompany 
them.  In  this  way,  all  the  chapters  can  be  prepared  and 
written  without  loss  of  time. 

All  original  data  should  be  kept  in  a  special  folder  and 
preserved  for  future  use.  All  typewritten  tables  should  be 
compared  with  the  originals,  and  corrections  made  wherever 
necessary.  The  tables  need  not  be  numbered  until  they 
are  all  ready  for  the  printer. 

Report  should  be  Perfect  before  Going  to  Printer.  — 
Before  the  report  is  submitted  to  the  printer,  care  should 
be  taken  to  have  the  typewritten  copy  entirely  correct, 
and  arranged  in  the  form  which  the  final  report  is  to  take. 
All  words  and  letters  which  are  to  be  in  capitals  should 
appear  so  in  the  copy.  The  paragraphing  and  the  arrange- 
ment of  the  chapters  should  be  definite  and  final.  The  size 
and  style  of  type,  the  size  of  the  type-page,  and  of  the 
printed  and  trimmed  page,  the  quaUty  of  paper,  the  loca- 
tion of  graphs,  tables  and  photographs  should  all  be  deter- 
mined before  the  copy  is  given  to  the  printer.  It  is  easier 
and  simpler  to  make  all  the  necessary  changes  and  all  the 
preliminary  arrangements  before  printing  is  actually  begun, 
as  the  attempt  to  make  such  changes  in  the  printed  copy 
consumes  too  much  time,  and  is  extremely  annoying.  It 
cannot  be  stated  too  emphatically  that  the  final  copy  should 
be  well-nigh  perfect. 

Proof  should  be  Carefully  Read.  —  After  the  copy  has 
been  given  to  the  printer,  the  type  will  be  set  up  by  chap- 
ters; and  the  galley-proof  of  each  chapter  will  be  ready 
in  a  short  time.  The  galley-proof  should  be  read  very 
carefully,  and  all  necessary  corrections  and  changes  should 
be  made.     The  places  where  the  tables,  graphs  and  photo- 


322        PREPARATION  OF  THE  REPORT 

graphs  are  to  be  inserted  should  be  clearly  specified.  While 
the  galley-proof  is  being  prepared,  cuts  should  be  made 
for  all  photographs  and  graphs  which  are  to  be  included, 
and  for  those  tables  which  are  not  to  be  printed  by  the 
ordinary  method.  All  tables  should  be  clearly  numbered, 
and  all  charts  may  be  designated  with  capital  letters. 
The  descriptive  matter  which  is  to  accompany  the  photo- 
graphs should  also  be  prepared. 

After  the  galley-proof  has  been  corrected,  it  is  returned 
to  the  printer  with  all  the  cuts;  and  the  page-proof  is  set 
up.  The  page-proof  will  look  exactly  like  the  finished 
product,  except  that  it  is  printed  on  ordinary,  cheap  paper, 
and  is  not  bound.  This  proof  should  be  carefully  re-read, 
for  any  final  changes  which  may  be  necessary  and  possible. 
The  corrected  page-proof,  which  should  be  flawless,  is  then 
returned  to  the  printer;  and  the  final  copy  is  prepared, 
cut,  bound  and  finally  placed  in  an  attractive  cover. 

Report  should  be  Attractively  Arranged  and  Printed.  — 
It  is  important  that  the  cover  be  attractive  and  pleasing. 
Such  a  cover  enhances  the  value  of  the  report  considerably, 
for  it  will  tempt  many  people,  who  might  not  otherwise 
be  interested,  to  pick  up  the  volume  and  read  it.  The 
paper  should  be  good,  the  type  sufficiently  large,  and  the 
spacing  satisfactory,  in  order  to  make  the  report  easy  to 
read.  A  standard  and  convenient  size  for  the  ])ound 
volume  is  6  by  9  inches. 

Each  chapter  should  begin  on  a  fresh  page.  Numerous 
photographs,  charts  and  tables  should  be  interspersed  in 
the  printed  matter,  so  that  there  are  few  pages  of  solid 
print.  This  arrangement  makes  the  report  more  readable 
and  very  attractive. 

Many  Photographs  Essential.  —  As  has  just  been  stated, 
the  health  survey  report  should  contain  numerous  photo- 
graphs. It  will  probably  be  impossible  to  print  all  the 
photographs  which  have  been  taken  during  the  course  of 


MAPS  SHOULD  BE  INCLUDED         323 

the  survey;  but  the  important  ones  should  be  selected, 
and  inserted  in  the  appropriate  chapters.  The  accompany- 
ing descriptions  should  not  b'e  too  long,  but  should  suffice 
to  describe  the  photographs  fully.  Almost  everybody  who 
opens  the  survey  report,  will  look  at  the  photographs; 
and  it  is  exceedingly  important  that  they  be  good,  suffi- 
ciently numerous,  and  described  in  such  a  way  that  each 
tells  a  complete  story.  As  far  as  possible,  the  story  of  the 
survey  should  be  told  by  photographs. 

Maps  of  Various  Kinds  should  be  Included.  —  The  re- 
port should  also  contain  a  map  of  the  city,  showing  the 
boundary  lines  of  the  wards,  the  rivers,  lakes  and  other 
points  of  general  interest.  Details,  such  as  the  location 
of  schools,  hospitals,  dispensaries,  clinics,  wells,  privies, 
and  nuisances  due  to  exposed  garbage,  manure  or  other 
organic  matter,  dairy  farms,  and  other  matters  of  public 
health  interest,  should  be.  placed  on  special  maps,  and 
should  be  included  in  the  appropriate  chapter.  The  report 
should  also  contain  a  table  of  contents,  giving  the  title  of 
each  chapter  and  the  page  on  which  it  begins.  If  the  report 
is  very  lengthy,  it  will  also  be  desirable  to  prepare  an 
index. 

The  writing  of  the  final  report  is  a  tremendous  task,  and 
consumes  much  time.  Anyone  who  undertakes  to  make 
a  public  health  survey  should  bear  in  mind  the  amount 
of  time  that  will  be  required.  The  actual  field  work  on 
most  surveys,  except  those  of  very  large  cities,  usually 
requires  about  one  month;  but,  if  a  particularly  thorough 
study  is  made,  it  may  require  approximately  two  months. 
The  longer  and  more  thorough  the  survey,  the  greater  the 
period  of  time  required  to  write  a  satisfactory  report. 
The  report  should  be  written  carefully  and  without  undue 
haste,  and  the  surveyor  should  allow  himself  ample  time 
in  which  to  perform  the  work  satisfactorily. 


CHAPTER   XIX 

RECOMMENDATIONS    FROM    OTHER    SURVEY 

REPORTS 

Recommendations  from  Selected  Reports.  —  It  may  be 
of  interest  to  the  surveyor  to  examine  various  recommen- 
dations made  as  a  result  of  previous  public  health  surveys 
and  incorporated  in  this  chapter.  No  attempt  will  be 
made  to  include  the  recommendations  of  all  the  surveys 
which  have  been  conducted  or  even  of  a  majority  of  them. 
We  shall  pass  over  the  recommendations  of  surveys  of 
state  health  organizations,  such  as  those  conducted  by 
Dr.  C.  V.  Chapin,  Surgeon  Carroll  Fox  and  the  National 
Child  Labor  Committee,  and  shall  confine  our  attention 
to  municipal  public  health  surveys  which  seem  to  be 
typical.  These  include  the  surveys  of  the  Russell  Sage 
Foundation,  the  Oklahoma  Public  Health  Surveys,  the 
surveys  conducted  by  the  Illinois  and  Maine  Departments 
of  Health,  the  Framingham  Community  Demonstration, 
the  surveys  of  Charleston,  W.  Va.,  Glen  Ridge,  N.  J.,  New 
Haven,  Conn.,  and  New  Orleans,  La.  As  far  as  possible, 
the  recommendations  listed  in  these  various  reports  are 
arranged  according  to  the  chapter  headings  employed  in 
this  book. 

Water-Supply 

Public  Health  Survey  of  Oklahoma  City,  Okla. 

1.    ''The  water-purification  plant  should  be  placed  under 

the  direction  of  a  trained  and  efficient  sanitary  engineer, 

who  should  not  only  supervise  the  operation  of  the  plant, 

but  should  conduct  chemical  and  bacteriological  tests  on 

324 


WATER-SUPPLY  325 

the  water-supply  to  determine  the  efficiency  of  operation 
and  the  safetj^  of  the  supply. 

2.  ''An  ordinance  should  be  framed  to  include  all  the 
recommendations  made  in  the  chapter  on  semi-public 
water-supplies,  aiming  to  insure  the  delivery  of  a  safe 
bottled  water." 

3.  ''Provision  should  be  made  for  the  frequent  inspec- 
tion of  semi-public  and  private  wells,  and  for  the  collection 
and  analysis  of  samples  of  water  from  the  public,  semi- 
public  and  private  water-supplies." 

Public  Health  Survey  of  Muskogee,  Okla. 

4.  "Reliable  engineers  should  be  employed  to  study  the 
need  of  more  thorough  purification  than  can  be  obtained 
through  the  present  methods  employed." 

5.  "The  public  water-supply  system  should  be  extended 
to  those  sections  of  the  city  where  it  is  not  available  at  the 
present  time." 

Public  Health  Survey  of  Bartlesville,  Okla. 

6.  "Reliable  engineers  should  be  employed  to  ascertain 
whether  a  new  source  of  water-supply  can  be  obtained, 
which  is  fresh  and  adequate,  so  that  the  public  supply 
may  be  adequately  treated  and  rendered  safe  and  palatable 
for  drinking  purposes." 

7.  "All  semi-public  water  companies  should  be  required 
to  introduce  methods  for  cleaning  and  sterilizing  the 
bottles  and  cans  satisfactorily." 

8.  "All  persons  associated  in  the  handling  and  delivery 
of  water  should  be  required  to  show,  by  undergoing  a 
thorough  medical  examination,  that  they  are  free  from 
disease." 

9.  "  Containers  used  for  delivering  drinking-water  should 
be  provided  with  dust-proof  caps,  and  the  stoppers  should 
be  sterilized  before  being  re-used." 


326  OTHER  SURVEY  REPORTS 

Public  Health  Survey  of  Enid,  Okla.    . 

10.  ''Provision  should  be  made  for  regular  chemical  and 
bacteriological  analyses  of  the  public  water-supply." 

11.  ''  The  main  portions  of  the  distributing  system  should 
be  safeguarded  against  emergencies,  so  that  the  city  will 
never  have  its  water-supply  cut  off." 

Public  Health  Survey  of  Shawnee,  Okla. 

12.  ''Immediate  steps  should  be  taken  to  increase  the 
capacity  of  the  sedimentation  basin  and  clear  well,  so  that 
an  adequate  period  of  sedimentation  may  be  obtained, 
and  at  least  a  day's  supply  may  always  be  on  hand  in  the 
clear  well." 

Public  Health  Survey  of  McAlester,  Okla. 

13.  "All  permits  to  hunt,  fish  or  picnic  on  the  water- 
shed should  be  rescinded  and  permanently  denied." 

14.  "Until  the  new  water-supply  and  treatment  plant 
are  ready  for  use,  the  public  supply  should  be  disinfected 
with  liquid  chlorine,. and  an  effort  should  be  made  to  remove 
the  objectionable  tastes  and  odors  due  to  algae,  by  treat- 
ment with  copper  sulphate.  The  public  should  be  educated 
to  have  confidence  in  the  safety  of  the  public  supply." 

15.  "All  water  lines  which  terminate  outside  the  home 
should  be  extended  so  that  the  facilities  may  be  available 
inside  the  house." 

Public  Health  Survey  of  New  Haven,  Conn. 

16.  "That  steps  be  taken  to  secure,  at  all  times,  the 
complete  safety  of  the  New  Haven  water  by  providing 
for  the  treatment  by  chlorination  of  the  Saltonstall,  Winter- 
green  and  Malt  by  supplies." 


SEWAGE  AND  SEWAGE  DISPOSAL  327 

Public  Health  Survey  of  Rockford,  III. 

17.  "All  connections  between  the  public  supply  mains 
and  factory  fire  protection  systems  should  be  abandoned 
at  the  earliest  date  consistent  with  securing  an  adequate 
substitute  independent  of  the  public  supply  mains." 

Sewerage  and  Sewage  Disposal 

Public  Health  Survey  of  Oklahoma  City,  Okla. 

1.  "The  municipality  should  investigate  the  immediate 
need  of  treating  the  sewage,  particularly  during  the  warm 
weather,  when  the  stream  flow  is  low." 

2.  "The  entire  city  should  be  completely  sewered  as 
soon  as  possible,  in  order  to  abolish  the  existing  privies." 

3.  "Those  privies  which  exist  on  property  abutting 
sewers  should  be  abandoned;  and  the  owners  should  be 
required  to  install  modern  flush-tank  toilets,  where  run- 
ning water  is  available." 

Public  Health  Survey  of  Muskogee,  Okla. 

4.  "The  M  Street  storm-sewer  should  be  a  closed  sewer 
for  a  distance  much  beyond  the  present  limit  of  human 
habitation  in  that  section  of  the  city,  and  preferably  up 
to  the  point  of  final  discharge." 

Public  Health  Survey  of  Bartlesville,  Okla. 

5.  "Until  the  city  is  completely  sewered,  the  privies 
should  be  made  safe  and  sanitary  in  the  manner  outlined 
in  the  report." 

6.  "During  the  periods  of  low  stream-flow  particularly, 
some  means  should  be  provided  for  treating  the  sanitary 
sewage,  in  order  to  prevent  the  Caney  River  from  becoming 
an  open  sewer." 

7.  "All  storm-sewers  should  be  thoroughly  inspected, 
and  remedial  measures  taken,  in  order  to  prevent  the  forma- 


328  OTHER  SURVEY  REPORTS 

tion  of  stagnant  pools  of  water  which  serve  as  breeding 
places  for  mosquitoes." 

Public  Health  Survey  of  Enid,  Okla 

8.  ''Means  for  treating  the  sewage,  such  as  are  outlined 
in  the  report,  should  be  provided,  in  order  to  overcome 
existing  nuisances  and  any  menace  to  the  pubUc  health; 
and  the  disposal  plant  should  be  placed  under  expert 
supervision." 

9.  ''An  intercepting  sewer  should  be  provided,  joining 
both  outfall  sewers,  so  that  all  the  sewage  may  be  con- 
veyed to  one  disposal  plant." 

Public  Health  Survey  of  Shawnee,  Okla. 

10.  "The  sewage  of  the  city  should  be  conducted  to 
one  point,  where  it  should  be  treated  adequately  before 
being  discharged;  the  first  flush  of  storm-sewage  should 
also  be  given  adequate  treatment." 

11.  "Fishing  near  the  sewer-outfalls  should  be  pro- 
hibited." 

Public  Health  Survey  of  McAlester,  Okla. 

12.  "The  present  practice  of  dumping  the  collected 
excreta  should  be  discontinued,  and,  until  a  sewage-treat- 
ment plant  becomes  available,  the  excreta  should  be 
buried." 

Public  Health  Survey  of  Ardmore,  Okla. 

13.  "A  well-trained  and  experienced  sanitary  engineer 
should  be  employed  to  supervise  and  control  the  operation 
of  the  two  sewage-disposal  plants,  and  to  assist  in  design- 
ing additional  sewers  for  the  city." 


REFUSE   COLLECTIO.N   AND   DISPOSAL  329 

Public  Health  Suevey  of  New  Haven,  Conn. 

14.  ''That,  pending  the  treatment  of  the  city  sewage, 
the  taking  of  shellfish  from  the  harbor  of  New  Haven  be 
prohibited,  except  under  such  precautions  as  will  ensure 
adequate  purification  before  they  are  used  as  food." 

15.  ''That,  pending  the  treatment  of  the  city  sewage, 
bathing  be  prohibited  in  the  more  grossly  polluted  portions 
of  the  harbor,  the  limits  of  the  prohibited  area  to  be  de- 
fined by  the  Board  of  Health." 

16.  "  That,  so  soon  as  the  experiments  on  sewage-disposal 
are  completed,  the  sewage  of  the  city  should  be  treated 
as  promptly  as  possible  by  such  means  as  seem  best  adapted 
to  eliminate  local  nuisances  and  render  the  harbor  waters 
safe  for  bathing  and  for  the  taking  of  shellfish." 

17.  "That,  in  the  drainage  operations  planned  for 
1917,  the  fresh  water  areas  which  are  likely  to  breed 
malarial  mosquitoes  (such  as  those  of  Beaver  Swamp,  on 
the  shores  of  West  River  and  of  Lake  Whitney,  and  in 
East  Haven)  should  receive  first  attention." 

18.  "That  the  Board  of  Health  modify  its  regulation  in 
regard  to  mosquito-breeding  receptacles  so  as  to  declare 
any  accumulation  of  stagnant  water  in  which  mosquitoes 
breed  to  be  a  public  nuisance." 

Refuse  Collection  and  Disposal 

Public  Health  Survey  of  Oklahoma  City,  Okla. 

1.  "A  system  of  free  municipal  collection  and  disposal 
of  refuse  should  be  introduced,  and  the  cost  of  this  new 
municipal  function  should  be  paid  from  the  general  tax." 

2.  "The  incinerator  should  be  properly  modified,  if  pos- 
sible, so  that  it  will  be  capable  of  destroying  all  rubbish 
and  similar  material;  but  the  garbage  should  be  fed  to 
hogs,  under  proper  supervision  and  management." 


330  OTHER  SURVEY  REPORTS 

3.  ''The  nuisances  resulting  from  exposed  or  improperly 
disposed  garbage  or  manure  should  be  remedied  through 
the  efforts  of  the  available  sanitary  inspector  and  pohce." 

Public  Health  Survey  of  Muskogee,  Okla. 

4.  "The  keeping  of  hogs  within  the  city  hmits  should 
be  discouraged." 

5.  "Tin  cans  and  other  non-combustible  material  should 
be  conveyed  to  the  city  dump,  and  covered  with  earth  in 
order  to  prevent  any  nuisance." 

Public  Health  Survey  of  Bartlesville,  Okla. 

6.  ''The  incinerator  which  is  available  should  be  placed 
in  constant  operation,  and  should  be  used  for  the  destruc- 
tion of  all  combustible  rubbish  and  dead  animals." 

7.  "Fly-tight,  water-tight  covered  wagons  should^  be 
employed  for  collecting  garbage,  and  all  unauthorized 
dumping  should  be  prohibited." 

8.  "The  piggeries  and  dumps  that  are  maintained  should 
be  operated  in  a  clean  and  inoffensive  manner." 

Public  Health  Survey  of  Enid,  Okla. 

9.  "The  collection  and  disposal  of  refuse  should  be 
placed  under  the  supervision  of  the  engineering  depart- 
ment." 

10.  "A  municipal  incinerator  should  be  provided,  to 
destroy  all  combustible  refuse,  dead  animals  and  excreta." 

11.  "Special  regulations  should  be  adopted  for  storing, 
collecting  and  disposing  of  manure." 

Public  Health  Survey  of  New  Haven,  Conn. 

12.  "That  the  present  system  of  garbage  collection 
should  be  improved,  so  as  actually  to  secure,  in  all  sections 
of  the  city,  the  regular  and  frequent  removals  now  called 


MILK-SUPPLY  331 

for  by  agreements  with  contractors;  and  that  a  regular 
pubHc  system  of  collection  be  instituted  for  other  classes 
of  refuse." 

Milk-Supply 

Public  Health  Survey  of  Oklahoma  City,  Okla. 

1.  ''A  well-trained,  able  and  efficient  milk  inspector 
should  be  employed  to  supervise  the  milk-supply,  and  to 
educate  the  farmers,  dealers  and  others  in  the  production 
of  a  good,  clean  and  safe  milk." 

2.  ''AH  food-handlers  should  be  required  to  submit  a 
certificate  of  health,  showing  that  they  are  known,  as  a 
result  of  a  thorough  medical  examination,  to  be  free  from 
disease." 

3.  ''All  milk  sold  in  the  city  should  be  pasteurized  by 
the  holding  method,  unless  it  meets  the  bacteriological 
requirements  outlined  in  the  chapter  on  milk-supply;  and 
all  pasteurizing  plants  should  employ  recording  ther- 
mometers in  order  to  show  the  temperature  and  time 
used." 

4.  "All  one-  and  two-cow  dairies  located  in  the  city 
should  be  licensed,  and  should  be  inspected  and  controlled, 
as  the  other  dairies  are." 

Public  Health  Survey  of  Muskogee,  Okla. 

5.  "The  tuberculin  test  should  be  performed  on  each 
herd  furnishing  milk  to  the  citv.  at  least  once  everv  vear." 

Public  Health  Survey  of  New  Haven,  Conn. 

6.  "That  all  milk  sold  in  New  Haven  be  graded  and 
labeled,  according  to  the  general  plan  that  has  been  fol- 
lowed by  the  New  York  State  Department  of  Health  and 
other  official  bodies." 

7.  "That  every  effort  be  made  to  secure,  as  rapidly  as 
may  be  feasible,  the  pasteurization  by  the  holding  method 


332  OTHER  SURVEY  REPORTS 

of  all  milk  not  of  certified  grade,  under  the  supervision  and 
control  of  the  Board  of  Health." 

Public  Health  Survey  of  Charleston,  W.  Va. 

8.  ''That  no  person  be  allowed  to  sell  or  distribute  milk 
in  Charleston  without  a  license,  for  which  a  fee  shall  be 
paid." 

9.  ''That  this  license  shall  be  renewed  annually." 

10.  "That  all  milk  shall  be  free  from  adulterants,  pre- 
servatives and  artificial  coloring-matter." 

11.  "That  all  milk  shall  contain  at  least  12  per  cent 
total  solids,  of  which  at  least  3.5  per  cent  shall  be  butter- 
fat." 

13.  "That  no  milk  shall  be  repasteurized." 

Public  Health  Survey  of  Rockford,  III. 

14.  "An  ordinance  should  be  passed  and  enforced,  pro- 
hibiting the  collection  and  use  of  milk-bottles  belonging  to 
one  dairy  by  another  dairy;  and  all  dairies  selling  milk  in 
Rockford  should  be  required  to  have  all  their  bottles 
marked  in  a  distinctive  manner." 

Organization  and  Activities  of  the  Health  Department 
Public  Health  Survey  of  Oklahoma  City,  Okla. 

1.  "The  health  department  should  be  reorganized  along 
the  lines  advocated  in  the  report." 

2.  "The  appropriation  for  the  health  department  should 
be  increased  to  the  proposed  amount,  in  order  to  permit 
the  reorganized  department  to  carry  on  its  activities  in  a 
thorough  and  modern  way." 

3.  "The  sanitary  and  milk  codes  should  be  revised,  so 
that  a  model  sanitary  law  may  be  put  into  effect.  The 
work  should  be  undertaken  by  the  new  health  officer, 
with  the  cooperation  and  aid  of  qualified  citizens  in  the 
community." 


MILK-SUPPLY  333 

4.  ''There  is  urgent  need  for  the  more  perfect  coordi- 
nation of  pubhc  health  nursing  activities.  Until  the 
health  department  is  able  to  take  over  this  work,  it  would 
be  advisable  to  organize  a  public  health  association  which 
would  have  charge  of  all  public  health  nursing  in  the  city." 

Public  Health  Survey  of  New  Haven,  Conn. 

5.  ''That  the  Board  of  Health  adopt  a  regulation,  de- 
claring malaria  to  be  a  notifiable  disease,  and  that  provision 
should  be  made  for  investigating  each  case  as  reported, 
in  order  to  determine  the  existence  of  local  foci  of  infection." 

6.  "That  Section  95  of  the  Charter  Act  be  amended,  so 
as  to  provide  that  the  Board  of  Health  shall  appoint  the 
Health  Officer  and  determine  the  general  policies  of  the 
department,  while  the  conduct  of  administrative  details 
shall  be  entrusted  to  the  Health  Officer,  and  all  appoint- 
ments of  other  employees  shall  be  made  by  him,  under  the 
rules  of  the  Civil  Service  Board." 

7.  "That  the  need  for  adequate  quarters  for  the  Depart- 
ment of  Health  be  vigorously  urged  upon  the  proper  city 
authorities." 

8.  "That  the  Board  of  Aldermen  take  such  action  as 
may  be  necessary  to  place  responsibility  for  the  inspection 
and  control  of  ordinary  nuisances,  such  as  are  due  to  the 
accumulation  of  rubbish  in  vacant  lots,  yards  and  the  like 
and  the  investigation  of  complaints  relating  thereto,  in 
the  hands  of  the  police  department,  so  that  the  inspectors 
of  the  health  department  may  devote  their  attention  to 
the  problems  of  fly  and  mosquito  control,  the  protection 
of  privy-vaults,  the  improvement  of  housing  conditions, 
and  other  matters  bearing  more  distinctly  upon  health." 

9.  "That  the  farm  inspector,  the  milk  inspector,  the 
two  food  inspectors,  the  four  sanitary  inspectors  (exclud- 
ing the  one  assigned  to  communicable  disease  work)  and 
the  Tenement  House  Inspector  be  organized  as  a  Bureau 


334  OTHER  SURVEY  REPORTS 

of  Inspection,  with  a  Chief  or  Supervising  Inspector  at  a 
salary  of  $2000,  to  be  chosen  by  competitive  examination 
from  the  ranks  of  the  present  staff." 

10.  ''That  steps  should  be  taken  to  provide  a  munici- 
pal slaughter-house  within  the  city  limits,  and  that  regu- 
lations be  included  in  the  Sanitary  Code  prohibiting  the 
sale  of  meat  which  has  not  been  passed  at  the  time  of 
slaughter,  either  by  Federal  Inspectors  or  those  of  the 
local  department  of  health." 

11.  ''That  the  promising  policies  of  the  Department  of 
Health  in  the  treatment  of  carriers  be  continued,  but  that 
they  be  supplemented  by  such  measures  of  control  of  frank 
cases  and  contacts  as  are  generally  considered  wise  and 
necessary  by  recognized  sanitary  authorities." 

12.  "That  information  disseminated  to  the  general 
public,  through  the  medium  of  the  annual  report,  monthly 
bulletin  and  other  publications  of  the  Department  of 
Health,  be  confined  to  those  scientific  facts  which  are 
generally  accepted  by  competent  leaders  in  the  fields  of 
medicine  and  public  health,  novel  and  controversial 
opinions  being  presented  to  the  proper  audience  through 
the  medium  of  the  scientific  press." 

13.  "That  Dr.  Lewis  (the  health  officer)  be  relieved  of 
the  responsibility  for  the  laboratory  of  the  Health  Depart- 
ment and  permitted  to  devote  himself  to  the  problems  of 
communicable  disease  control;  and  that  he  be  provided 
with  a  public  health  nurse  at  $1000,  and  a  clerk  at  $600, 
for  the  adequate  prosecution  of  this  work." 

14.  "That  the  Department  of  Health  undertake  a 
vigorous  educational  campaign  among  physicians  and  the 
general  public,  in  the  interest  of  a  more  general  and  more 
prompt  use  of  diphtheria  antitoxin,  and  a  wider  protection 
of  the  public  against  typhoid  and  smallpox,  by  the  use  of 
vaccines." 

15.  "That  the  laboratory  work  of  the  Department  of 


MILK-SUPPLY  335 

Health  be  separated  from  the  medical  work  of  communi- 
cable disease  control,  and  placed  under  the  direction  of  a 
bacteriologist  at  S2000,  with  an  assistant  chemist  at  $1200 
and  the  present  technician  to  assist  him;  that  the  work 
of  the  laboratory  be  reorganized  along  the  generally 
accepted  lines  of  standard  procedure  and  expanded,  as 
rapidly  as  possible,  to  include  quantitative  bacteriological 
examination  of  milk,  Wassermann  tests,  examination  for 
typhoid  carriers,  and  identification  of  pneumococcal  types 
for  assistance  in  the  administration  of  sera." 

16.  ''That  a  definite  plan  for  cooperation  in  the  sum- 
mer campaign  against  infant  mortality  be  worked  out  by 
conference  between  the  Department  of  Health  and  the 
Infant  Welfare  Association." 

17.  "That  the  city  appropriate  the  sum  of  $3000  an- 
nually, to  be  expended  by  the  Infant  Welfare  Association 
and  the  Visiting  Nurse  Association  for  the  establishment 
of  an  additional  station  and  for  further  infant  welfare 
work,  particularly  along  the  lines  of  prenatal  care  and  the 
organization  of  Little  Mothers'  League." 

18.  ''That  an  obstetrical  nurse,  at  a  salary  of  $1200,  be 
added  to  the  staff  of  the  Department  of  Health,  to  super- 
vise the  work  of  registered  midwives." 

19.  "That  the  Board  of  Health  undertake  an  organized 
educational  campaign  among  physicians,  in  regard  to  the 
prompt  diagnosis  and  notification  of  venereal  diseases,  and 
prepare  a  circular  in  regard  to  the  prevention  and  cure  of 
these  diseases,  for  distribution  to  those  whom  it  might 
benefit." 

20.  "That  the  Civic  Federation  organize  a  committee 
on  Social  Hygiene,  to  study  the  general  problems  of  venereal 
disease  in  New  Haven,  to  raise  funds  for  the  provision  of 
salvarsan  treatment,  and  for  the  extension  of  clinical 
facilities,  particularly  on  the  social  service  side,  to  take 
part    in    the    state-wide    educational    movement    now    in 


336  OTHER  .SURVEY  REPORTS 

progress    in    regard    to   the   broader   problems   of    social 
hygiene." 

21.  "That  the  public  health  education  work  of  the 
Department  of  Health  be  extended  and  amplified,  especially 
with  reference  to  the  control  of  the  constitutional  diseases 
of  adult  life,  and  particularly  by  the  fullest  possible  use 
of  the  resources  of  the  daily  press." 

Public  Health  Survey  of  Springfield,  III. 

22.  '^  Registration,  examination  and  regulation  of  mid- 
wives." 

23.  ''The  employment  of  public  health  nurses  who  are 
qualified  to  visit  homes  and  instruct  mothers  who  would 
not  ordinarily  receive  proper  advice  regarding  the  care  of 
infants;  this  work  to  be  carried  on  in  connection  with  one 
or  more  infant  welfare  or  consultation  stations,  where 
instruction  and  demonstrations  may  be  given  mothers, 
and  at  which  a  doctor  shall  be  in  attendance  at  certain  set 
hours,  and  to  which  sick  infants  may  be  brought.  This 
work  should  be  carried  on  by  the  city  health  department." 

24.  ''There  should  be  more  detailed  investigation  of 
cases  of  communicable  disease  and  of  the  possible  relation 
between  cases,  accompanied  by  examination  of  persons 
who  have  been  in  contact  with  the  case  to  discover  mild 
and  incipient  cases  and  carriers.  This  would  naturally 
require  more  complete  history  cards,  the  preparation  of 
maps  showing  the  distribution  and  spread  of  diseases,  and 
the  like." 

25.  "There  should  be  closer  supervision  of  cases  of 
diphtheria  and  scarlet  fever,  including  a  prompt  initial 
visit  by  a  medical  inspector,  or  a  specially  trained  nurse, 
employed  by  the  health  department  to  issue  detailed 
instructions  as  to  the  maintenance  of  the  patient  and  the 
disinfection  of  discharges;  re-inspections  to  follow  at  fre- 
quent intervals  to  see  that  instructions  are  being  followed, 


MILK-SUPPLY  337 

with  release  only  after  a  final  inspection  by  a  medical 
representative  of  the  health  department.  In  the  case  of 
diphtheria,  release  only  after  two  successive  negative  cul- 
tures from  the  nose  and  throat." 

26.  ''There  should  be  visits  to  cases  of  measles  and 
whooping-cough,  in  order  to  instruct  the  responsible 
parties  as  to  the  management  of  the  patient  and  the  dis- 
infection of  his  discharges." 

27.  ''There  should  be  a  transference  of  the  present  em- 
phasis on  fumigation  at  the  termination  of  the  case,  to 
bedside  disinfection  of  discharges  during  the  activity  of 
the  disease  and  general  cleaning  at  its  termination." 

28.  "That  a  full-time  health  officer  be  employed.  The 
health  officer  should  be  appointed  for  a  term  of  years  and 
should  be  given  a  free  rein  over  his  department." 

29.  "That  pubHc  health  nurses  should  be  employed  to 
carry  on  work  against  tuberculosis  and  infant  mortality. 
The  employment  of  such  nurses  should  take  precedence  over 
that  of  any  other  additional  persons,  such  as  inspectors." 

30.  "That  an  epidemiologist  should  be  employed,  who 
might  also  act  as  medical  inspector  in  contagious  diseases." 

31.  "That  systematic  efforts  at  health  education  and 
publicity  should  be  initiated." 

32.  "That  there  should  be  a  shifting  of  emphasis  in  the 
control  of  communicable  diseases,  from  quarantine  of  the 
premises  and  fumigation,  to  early  recognition  of  all  cases 
and  efficient  bedside  disinfection  of  the  patient's  dis- 
charges. There  should  also  be  greater  strictness  in  the 
matter  of  release  from  quarantine,  in  diphtheria  by  the 
culture  method  only,  and  in  scarlet  fever  only  after  inspec- 
tion of  the  patient  by  a  medical  representative  of  the 
health  department." 

33.  "That  work  against  the  venereal  diseases  should  be 
initiated,  such  as  has  been  instituted  by  progressive  health 
departments  in  other  cities." 


338  OTHER  SURVEY  REPORTS 

Public  Health  Survey  of  New  Orleans,  La. 

34.  ''Laboratory  workers  should  be  protected  against 
infection  from  suspected  tuberculous  sputa,  by  inserting  a 
small  amount  of  disinfectant  in  each  sputum  bottle." 

35.  ''The  physicians  should  be  stimulated  to  make 
greater  use  of  the  public  health  laboratory  facilities.  Col- 
lecting stations  should  be  established  where  the  physician 
may  conveniently  leave  his  "specimens  for  diagnosis." 

The  Public  Health  Survey  of  Lewiston  axd  Auburn, 

Maine 

36.  "That  the  public  health  administration  of  Lewiston 
and  Auburn  be  placed  in  the  hands  of  a  modern  coopera- 
tive health  department." 

37.  "That  the  proposed  health  department  take  over 
all  public  health  work  now  done  by  both  public  and  private 
agencies." 

Inspection  of  Restaurants,  Lunch  Rooms  and  Food- 
Stores 

Public  Health  Survey  of  Oklahoma  City,  Okla. 

L  "All  food-stores,  lunch  rooms  and  restaurants  should 
be  examined  more  frequentl}',  in  order  that  the  defects 
brought  out  by  the  inspections  may  be  remedied." 

2.  "All  food-handlers  should  be  required  to  show  a 
certificate  of  health,  obtained  as  a  result  of  a  thorough 
medical  examination." 

Public  Health  Survey  of  Muskogee,  Okla. 

3.  "In  the  proposed  revision  of  the  sanitary  code,  which 
is  recommended,  a  regulation  should  be  inserted  providing 
for  the  satisfactory  cleansing  and  sterilization  of  soda- 
water  glasses  or  the  use  of  individual  paper  containers." 


HOUSING  339 

Housing 
Public  Health  Survey  of  Oklahoma  City,  Okla. 

1.  ''The  housing  evils  resulting  from  open  privies,  in- 
adequate or  polluted  water-supplies  and  improper  disposal 
of  garbage  should  be  remedied  by  frequent,  intelligent 
inspections  and  education,  and  by  the  extension  of  the 
facilities  of  municipal  sanitation  to  those  sections  not  yet 
provided  therewith." 

2.  ''Efforts  should  be  made  by  legislation,  fines  and 
education,  to  prevent  tenement  houses  from  being  built 
in  the  city,  and  also  to  overcome  such  evils  as  overcrowd- 
ing, and  the  use  of  dark  and  small  rooms." 

3.  "The  supervision  and  regulation  of  housing  facilities 
from  the  standpoint  of  the  health,  comfort  and  convenience 
of  the  people  should  become  one  of  the  functions  of  the 
reorganized  health  department." 

Public  Health  Survey  of  Bartlesville,  Okla. 

4.  "The  Chamber  of  Commerce  or  some  other  organi- 
zation should  devise  means  for  building  model  homes  in 
Smeltertown  at  a  sufficientl}^  low  rental,  but  which  will  be 
high  enough  to  give  a  satisfactory  return  on  the  invest- 
ment." 

5.  "The  smelter  companies  should  be  required  to  treat 
the  obnoxious  and  injurious  gases  which  are  emitted  by 
the  smelters,  so  that  the  residents  of  Smeltertown  may  be 
freed  from  this  great  annoyance  and  injury  to  their  health 
and  comfort." 

Public  Health  Survey  of  New  Haven,  Conn. 

6.  "That  the  Committee  on  Tenement  House  Condi- 
tions of  the  Civic  Federation  investigate  the  present 
Housing  Laws  of  Connecticut  and  consider  the  advisability 


340  OTHER  SURVEY  REPORTS 

of  strengthening  them  along  the  hnes  of  the  Model  Housing 
Law,  or  of  supplementing  them  by  more  exacting  municipal 
ordinances,  particularly  so  as  to  guard  against  lot  over- 
crowding, dark  halls,  and  dark  toilets,  in  new  buildings, 
and  to  provide  for  adequate  fire-escapes  in  both  new  and 
old  buildings." 

7.  "That  the  Committee  on  Tenement  House  Condi- 
tions of  the  Civic  Federation  inaugurate  a  systematic 
campaign  for  the  widest  possible  extension  of  activities  of 
the  Improved  Housing  Association,  to  the  end  of  provid- 
ing, through  private  endowment,  for  more  model  homes; 
and  that  the  Committee  give  consideration  to  the  possi- 
bility of  securing  from  the  city  government  appropriations 
for  municipal  tenements,  such  as  have  been  so  successfully 
operated  by  European  municipalities." 

Public  Health  Survey  of  New  Orleans,  La. 

8.  "The  Housing  Code  should  be  revised  to  include  all 
dwellings.  As  it  now  stands,  the  housing  code  applies 
only  to  residences  where  three  or  more  families  live  inde- 
pendently and  cook  their  meals  on  the  same  premises. 
The  double  frame  cottage,  the  prevailing  type  of  dwelling, 
does  not  come  under  the  Housing  Code." 

9.  "iModern  homes,  providing  adequate  ventilation  and 
privacy,  should  be  provided  at  a  reasonable  price." 

10.  "Legislation  should  be  directed  toward  the  im- 
provement of  homes  for  the  negro,  and  to  prevent  the 
building  of  wooden  shacks  in  rows." 

U.  "Larger-sized  lots  and  the  abolition  of  the  present 
high  board  fence  would  tend  to  reduce  the  fire  hazard  in  New 
Orleans,  and  at  the  same  time  furnish  better  ventilation." 

12.  "All  homes  should  be  provided  with  convenient 
bathing  facihties." 

13.  "Studies  in  city  planning  should  be  made,  to  make 
a  city  beautiful." 


SCHOOL   SANITATION  341 

School  Sanitation 

Public  Health  Survey  of  Oklahoma  City,  Okla 

1.  "Adequate  and  proper  drinking,  toilet  and  washing 
facilities  should  be  provided  in  each  school." 

2.  "The  question  of  heating  and  ventilation  should  be 
studied  along  the  lines  advocated  in  the  report." 

3.  "The  seats  and  desks  should  be  adjusted  to  the 
requirements  of  each  child,  at  least  twice  a  year." 

4.  "Additional  schools  should  be  provided  to  replace  the 
old  ones,  and  to  minimize  overcrowding." 

5.  "Every  school  building  should  be  made  thoroughly 
safe  against  danger  from  fire." 

Public  Health  Survey  of  Muskogee,  Okla. 

6.  "Safe  and  sanitary  privies  should  be  substituted  for 
those  in  use." 

7.  "Proper  bubbling  fountains  should  be  substituted  for 
those  in  use,  and  safe  drinking-water  should  be  provided 
where  such  facilities  are  absent." 

Public  Health  Survey  of  Ardmore,  Okla. 

8.  "Soap  and  individual  towels,  in  addition  to  running 
water,  should  be  furnished  in  the  toilets  of  every  school 
where  city  water  is  available." 

9.  "Adjustable  seats  and  desks  should  be  introduced  in 
the  schools  as  rapidly  as  possible." 

10.  "Additional  schools  should  be  provided  in  the 
future  as  the  necessity  for  them  arises,  instead  of  building 
additions  to  the  existing  schools." 

11.  "Overcrowding  should  be  diminished  in  those  class 
rooms  where  it  is  prevalent." 


342  OTHER  SURVEY  REPORTS 

Public  Health  Survey  of  Bartlesville,  Okla. 

12.  ''Proper  bubbling  fountain  facilities  should  be  pro- 
vided in  place  of  the  water  troughs." 

Public  Health  Survey  of  Enid,  Okla. 

13.  "Proper  bubbling  fountain  facilities  should  be  intro- 
duced, to  replace  the  water-coolers  now  in  use." 

Framingham  Monograph  No.  G 

14.  ''Systematic  correction  of  thermostats,  the  stand- 
ardization of  thermometers,  and  a  more  accurate  system 
of  recording  to  improve  temperature  control." 

15.  "The  instruction  and  supervision  of  janitors  as 
regards  artificial  ventilation  equipment,  and  the  encourage- 
ment of  the  teachers'  cooperation  where  natural  methods 
of  ventilation  are  depended  upon." 

16.  "The  elimination  of  dust  by  school-room  cleanli- 
ness, and  hygienic  methods  of  cleaning  erasers." 

17.  "An  effort,  wherever  possible,  to  correct  the  inade- 
quacy of  school-room  glass  area." 

18.  "Where  new  building  equipment  is  not  immediately 
anticipated,  a  certain  amount  of  rearrangement,  as  regards 
windows  and  natural  light,  would  greatly  improve  illu- 
mination." 

19.  "The  intelligent  supervision  in  the  selection  of  wall 
colorings,  the  placing  of  blackboards,  etc.,  for  the  control 
of  glare." 

20.  "The  elimination  of  glare  factors  through  minor 
changes  in  equipment,  as  regards  artificial  illumination." 

21.  "An  effort  to  keep  window-shades  in  woiking  order, 
and  the  replacement  of  shades  which  roll  from  the  top  by 
the  less  obstructive  type,  recommended  in  the  report, 
particularly  in  the  darker  rooms." 


SCHOOL   HYGIENE  343 

22.  "Expert  supervision  and  inter-term  attention  in  the 
matter  of  seating  adjustment." 

23.  "An  effort  gradually  to  bring  up  to  date  the  seating 
equipment  throughout  the  schools." 

24.  "The  replacement  of  the  antiquated  and  continually 
out-of-order,  unsanitary  trough  equipment  with  modern 
toilet  and  urinal  units." 

25.  "Improved  supervision  of  toilet  facilities  as  regards 
heating,  ventilation,  illumination,  cleanliness  and  essential 
supplies." 

26.  "The  arrangement  of  washing  facilities  in  regard  to 
their  availability  in  connection  with  toilet  equipment." 

27.  "The  improvement  of  hand-washing  equipment, 
with  attention  to  soap,  individual  towels,  hot  water,  and 
either  bowls  or  non-spring  faucets." 

28.  "The  elimination  of  all  possible  sources  of  contact 
in  the  drinking  facilities,  such  as  common  cups." 

29.  "The  provision  of  adequate  drinking  facilities,  and 
the  insistence  on  drinking  fountains  of  an  hygienic  type." 

Public  Health  Survey  of  New  Orleans,  La. 

30.  "New  buildings  should  be  erected,  or  other  means 
provided,  so  that  the  present  system  of  holding  classes  in 
damp  basements  can  be  abolished." 

School  Hygiene 
Public  Health  Survey  of  Oklahoma  City,  Okla. 

1.  "The  school  hygiene  work  should  be  reorganized,  ac- 
cording to  the  plan  outlined  under  the  reorganization  of 
the  health  department." 

2.  "A  complete,  thorough  and  scientific  examination  of 
each  child  should  be  conducted  every  year;  the  data  should 
be  recorded  on  a  single  card  which  should  follow  the  child 
from  one  class  to  another  throughout  its  school  career." 


344  OTHER  SURVEY  REPORTS 

3.  ''The  number  of  home  visits  by  the  school  nurses 
should  be  materially  increased  for  those  cases  that  require 
attention." 

4.  "All  defects  that  are  discovered  should  be  followed 
up  until  they  are  remedied;  and  provision  should  be  made 
for  needy  cases  to  receive  the  treatment  necessary  for 
curing  the  defects." 

5.  ''Health  instruction  in  the  schools  should  be  made  a 
part  of  the  curriculum,  and  the  subjects  made  interesting 
and  attractive  by  proper  presentation." 

6.  "Open-air  classes  should  be  provided  in  all  new 
school  buildings  and  the  wooden  annexes  should  be  con- 
verted into  open-air  schools.  Such  provision  is  necessary 
for  the  proper  care  of  the  physically  handicapped  children." 

Public  Health  Survey  of  Muskogee,  Okla. 

7.  "A  school  nurse  should  be  employed  to  make  the 
home  visits,  and  thus  relieve  the  medical  inspector  of  this 

task." 

8.  "A  dental  clinic  should  be  established,  and  a  dentist 
employed  on  a  part-time  basis,  to  discover  dental  defects 
and  to  render  the  necessary  aid  in  needy  cases." 

Public  Health  Survey  of  Bartlesville,  Okla. 

9.  "A  medical  inspector,  school  nurse  and  school  dentist 
should  be  employed  to  conduct  the  work  of  school  hygiene 
outlined  in  the  report." 

Public  Health  Survey  of  New  Haven,  Conn. 

10.  "That  the  work  of  the  medical  school  inspection  be 
reorganized  and  expanded  along  the  lines  laid  down  in  this 
report,  to  include  the  organization  of  medical  clinics,  with 
the  provision  of  the  following  new  appointees  in  addition 
to  the  present  staff:    a  medical  supervisor  at  $2500;    a 


HOSPITAL   FACILITIES  345 

supervising  nurse  at  $2000;  two  clinic  nurses  at  $850 
each;  a  clerk  at  $750;  an  additional  dentist  at  $1000,  and 
an  additional  dentist's  assistant  at  $400." 

Framingham  Monograph  No.  6 

11.  "The  hygienic  education  of  the  school  children  re- 
garding the  proper  use  of  the  school  sanitary  equipment." 

12.  ''Full  attention  to  the  hygienic  demands  of  school 
life  in  the  general  program  for  the  development  of  public 
school  facilities  in  Framingham." 

13.  ''The  continued  development  and  maintenance  of 
the  excellent  administrative  machinery  and  personnel  for 
medical,  nursing,  cHnical  and  hygienic  control  among  the 
school  population." 

Public  Health  Survey  of  New  Orleans,  La. 

14.  "There  should  be  one  nurse  for  every  1500  pupils, 
and  one  physician  for  every  3000  pupils  in  order  to  super- 
vise the  health  of  the  children  adequately." 

15.  "Children  should  be  instructed  in  a  tooth-brush 
drill,  with  occasional  short  talks  on  dental  prophylaxis." 

16.  "Open-air  schools  for  children  predisposed  to  tuber- 
culosis should  be  erected." 

17.  "Lunches  of  hot,  nourishing  food  should  be  served 
to  school  children,  especially  in  the  schools  where  children 
are  drawn  from  the  poorer  quarters  of  the  city." 

Hospital  Facilities 
Public  Health  Survey  op  Oklahoma  City,  Okla. 

1.  "A  new,  modern,  centrally  located  and  scientifically 
operated  contagious  disease  hospital  should  be  provided." 

2.  "Provision  should  be  made  for  increasing  the  num- 
ber of  beds  in  the  better  hospitals  particularly,  in  order  to 


346  OTHER  SURVEY  REPORTS 

keep  pace  with  the  demands  placed  upon  them  from  all 
parts  of  the  state." 

Public  Health  Survey  of  Muskogee,  Okla. 

3.  ''At  least  100  additional  beds  should  be  provided  by 
erecting  a  new  hospital,  in  order  to  relieve  the  overcrowd- 
ing that  exists,  and  to  overcome  the  lack  of  adequate 
facilities." 

4.  ''The  fire  menace  which  threatens  the  Baptist  Hos- 
pital should  be  removed." 

5.  "Adequate  provision  should  be  made  for  the  sick 
poor." 

Public  Health  Survey  of  Enid,  Okla. 

6.  "Such  evils  as  poor  washing  facilities  in  operating 
rooms,  the  use  of  the  common  towel,  the  common  drinking- 
cup  and  others  which  have  been  mentioned  in  the  report, 
should  be  remedied." 

Public  Health  Survey  of  New  Haven,  Conn. 

7.  "That  the  opportunities  for  hospital  isolation  offered 
by  the  Isolation  Building  of  the  New  Haven  Hospital  be 
more  fully  utilized,  and  that  cases  of  typhoid  fever  be 
hospitalized,  whenever  they  cannot  be  properly  cared  for 
at  home." 

Anti-Tuberculosis  Activities 
Public  Health  Survey  of  Oklahoma  City,  Okla. 

1.  "A  municipal  or  county  tuberculosis  hospital,  built 
and  maintained  by  the  municipality  or  the  county,  should 
be  provided,  and  should  have  a  minimum  capacity  of  50 
beds." 

2.  "The  tuberculosis  dispensary  service  should  be 
extended  to  include  special  negro  clinics.  There  should 
also  be  one  evening  clinic  during  the  week." 


ANTI-TUBERCULOSIS   ACTIVITIES  347 

Public  Health  Survey  of  Muskogee,  Okla. 

3.  ''The  tuberculosis  nurses  should  attempt  to  reach  a 
larger  number  of  children  exposed  to  tuberculosis  in  the 
home.  This  may  make  it  possible  to  recognize  a  great 
many  early  cases  of  the  disease,  and,  in  many  instances, 
may  prevent  the  disease  from  assuming  an  active  form." 

Public  Health  Survey  of  New  Haven,  Conn. 

4.  ''That  the  Department  of  Health  adopt  vigorous 
measures  for  the  control  of  the  wilfully  careless  consump- 
tive, by  forcible  control  when  necessary,  along  the  lines 
adopted  in  dealing  with  other  forms  of  communicable 
disease." 

5.  "That  the  city  appropriate  $3000  a  year,  for  extend- 
ing the  work  of  the  Visiting  Nurse  Association  in  the  care 
and  prevention  of  tuberculosis,  and  $2000  a  year  for  the 
maintenance  of  the  Day  Camp;  and  that,  pending  such 
an  arrangement,  every  effort  be  made  to  maintain  the  Day 
Camp  through  the  generosity  of  private  individuals." 

6.  "That  there  be  added  to  the  staff  of  the  Department 
of  Health  a  competent  physician  trained  in  anti-tuberculosis 
work  (at  a  salary  of  $2500)  to  supervise  and  coordinate 
and  develop  the  campaign  against  this  disease  along  the 
most  effective  lines." 

Public  Health  Survey  of  New  Orleans,  La. 

7.  "There  should  be  at  least  one  bed  for  every  two 
deaths  from  tuberculosis  each  year.  This  will  provide  at 
least  six  months'  hospital  care  for  each  case.  In  New 
Orleans  this  will  mean  about  500  hospital  beds,  equally 
divided  for  the  whites  and  the  colored." 

8.  "The  tuberculosis  clinics  should  obtain  the  services  of 
trained  diagnosticians,  some  of  whom  will  be  available  for 
evening  service." 


348  OTHER  SURVEY  REPORTS 

9.  Camp  Hygeia,  maintained  by  the  Louisiana  Anti- 
Tuberculosis  League,  should  be  enlarged  to  accommodate 
cases  which  cannot  be  successfully  treated  in  the  home. 
Provision  should  also  be  made  for  negro  patients.  There 
should  also  be  a  physician  in  attendance  at  the  camp." 

10.  ''Day  camps  should  be  provided  for  children  from 
tuberculous  families." 

IL  ''Sputum  cups  should  be  purchased  by  the  Board 
of  Health  for  general  distribution." 

Vital  Statistics 

Public  Health  Survey  of  Oklahoma  City,  Okla. 

L  "A  continued,  active  and  vigorous  campaign  should 
be  instituted  among  the  physicians,  for  the  complete  and 
accurate  reporting  of  cases  of  communicable  disease  and 
deaths.  The  model  vital  statistics  law  adopted  by  the 
state  should  be  the  guide  in  reporting  all  the  vital 
statistics." 

2.  "All  vital  statistics  should  be  reported  to  the  City 
Superintendent  of  Health." 

Public  Health  Survey  of  Shawnee,  Okla. 

3.  "The  registration  area  of  the  city  should  only  include 
the  legal  limits  of  the  municipahty." 

Public  Health  Survey  of  New  Haven,  Conn. 

4.  "That  the  office  of  Registrar  of  Vital  Statistics  be 
abolished,  and  that  a  statistician  at  $2000,  and  a  clerk  at 
SIOOO,  be  added  to  the  staff  of  the  Department  of  Health." 

5.  "That  the  vital  statistics  published  in  the  annual 
report  of  the  Department  of  Health  be  extended  and 
modified  so  as  to  present  the  fundamental  data  generally 
recognized  as  essential  by  vital  statisticians." 


ANALYSIS  OF  CITY  BUDGET  349 

Public  Health  Survey  of  Springfield,  III. 

6.  '^That  there  should  be  greater  insistence  on  the  more 
accurate  certification  of  death  by  physicians." 

7.  ''There  should  be  prompter  and  fuller  reporting  of 
cases  of  communicable  disease.  It  is  suggested  that  the 
health  department  furnish  physicians  with  sets  of  post- 
card forms  for  this  purpose,  and  that  written  confirmation 
of  telephonic  reports  be  required." 

Public  Health  Survey  of  Portland,  Maine 

8.  ''That  no  burial  be  allowed  without  a  permit." 

9.  "That  no  burial  permit  be  issued  prior  to  the  receipt 
of  a  certificate  of  death,  signed  by  the  attending  physician, 
except  in  cases  of  unavoidable  delay,  when  an  emergency 
certificate  may  be  accepted,  to  be  replaced  within  two 
weeks  by  the  physician's  certificate." 

10.  "That  the  local  health  officer  be  appointed  sub- 
registrar  of  vital  statistics  and  all  certificates  be  filed  with 
him." 

Analysis  of  City  Budget 
Public  Health  Survey  of  Oklahoma  City,  Okla. 

1.  "The  budget  for  the  protection  of  the  public  health 
should  be  increased  to  at  least  $0.50  per  capita,  in  accord 
with  the  plan  of  reorganization  outlined  for  the  city  health 
department;  and  this  money  should  be  placed  in  charge 
of  a  well-trained,  experienced  and  reliable  health  officer." 

Public  Health  Survey. of  Bartlesville,  Okla. 

2.  "Similar  to  above,  except  that  per  capita  appropria- 
tion should  be  $1.25." 

Public  Health  Survey  of  Enid,  Okla. 

3.  "Similar  to  No.  1,  except  that  per  capita  appropria- 
tion should  be  $0.64." 


350  OTHER  SURVEY  REPORTS 

Public  Health  Survey  of  Shawnee,  Okla. 

4.  "Similar  to  No.  1,  except  that  per  capita  appropria- 
tion should  be  $0.72." 

Public  Health  Survey  of  New  Haven,  Conn. 

5.  ''That  the  budget  of  the  New  Haven  Health  Depart- 
ment be  increased  from  $40,000  to  $74,000,  so  as  to  make 
possible  the  various  extensions  of  its  activities  specified  in 
earlier  recommendations." 


CHAPTER   XX 

METHODS   OF   OBTAINING   RESULTS   FROM 
THE   PUBLIC    HEALTH    SURVEY 

Public  Interest  must  be  Capitalized  Immediately.  —  It 
is  comparatively  simple  to  conduct  a  public  health  survey, 
in  spite  of  the  numerous  obstacles  and  difficulties  which 
are  usually  encountered.  But  it  is  exceedingly  difficult, 
in  comparison,  to  make  use  of  the  knowledge  obtained, 
and  to  introduce  the  improvements  which  have  been 
recommended.  Yet  it  is  the  extent  to  which  the  recom- 
mendations are  carried  out  that  determines  the  success  of 
the  survey  from  the  community's  point  of  view.  Doubt- 
less the  people  have  profited  by  the  campaign  of  education 
which  has  been  conducted  during  the  survey;  but,  if  the 
recommendations  are  not  put  into  practice,  the  benefits 
derived  will  probably  prove  to  be  fleeting  and  temporary. 

During  the  survey,  the  community  becomes  aroused  and 
interested  in  matters  pertaining  to  the  public  health;  and 
it  is  then  in  the  proper  mood  to  accept  and  introduce 
reforms.  The  interest  of  the  people  should  not  be  allowed 
to  cool,  if  it  is  at  all  possible  to  maintain  it.  On  this 
account  it  is  very  important  to  prepare  and  publish  the 
final  report  as  soon  as  possible.  The  presentation  of  the 
preliminary  report  is  necessary  and  its  publication  desir- 
able; but  the  entire  community  will  be  waiting  for  the 
final  report  which  contains  ''all  the  facts." 

If  the  publication  of  the  final  report  is  delayed  very 
long,  the  people  soon  forget  about  the  survey  and  lose 
interest.     Then,   when  the  report  is  finally  made  public 

351 


352  METHODS  OF  OBTAINING  RESULTS 

and  the  leaders  attempt  to  introduce  the  reforms  sug- 
gested, they  will  have  to  reawaken  the  enthusiasm  which 
prevailed  during  the  survey.  To  do  so  is  extremely  diffi- 
cult; and  for  this  reason  it  is  very  important  to  reap  the 
benefits  of  the  survey,  while  the  people  are  interested  and 
in  an  expectant  mood. 

Intelligent  and  Efficient  Leaders  Necessary  for  Results. 
—  In  order  to  obtain  lasting  results  from  the  survey,  it 
will  be  necessary  to  work  through  one  or  more  committees, 
representing  the  best  public  spirit  of  the  community.  In 
any  case,  some  individual  who  is  an  outstanding  figure  in 
the  communit}^  and  is  capable  of  being  a  leader  should 
always  be  induced  to  take  charge  of  the  post-survey  work. 
On  him  will  devolve  the  responsibility  of  arranging  meet- 
ings for  the  committeemen,  of  keeping  the  aims  of  the 
survey  and  its  recommendations  before  the  public  eye, 
and  of  agitating  constantly,  until  the  goal  has  been  attained. 
The  individual  selected  should  preferably  be  one  who  is 
trained  in  public  health  work,  and  who  is  an  able  organizer 
and  community  worker.  He  must  necessarily  have  been 
associated  with  the  survey  while  it  was  in  progress,  and 
must  be  familiar  with  most  of  the  details  brought  out  by 
the  investigation.  He  should  be  acquainted  with  the 
principal  recommendations,  and  should  strive  toward  the 
immediate  adoption  of  those  which  are  most  urgent. 

Final  Report  should  Reach  Central  Committee  Soon 
after  Survey.  —  When  the  final  report  is  completed,  a 
copy  should  immediately  be  placed  in  the  hands  of  the 
chairman  of  the  central  committee.  If  the  reports  have 
been  printed,  each  member  of  the  central  committee  should 
receive  a  copy.  A  meeting  of  this  committee  should  then 
be  called,  and  the  work  of  the  survey  should  be  outlined 
to  its  members,  with  particular  emphasis  on  the  findings 
and  the  recommendations.  This  can  be  done  by  the 
chairman,   by   the   individual   who   has   been   selected  to 


SPECIAL  COMMITTEE  353 

introduce  the  recommendations,  or  by  the  expert  himself, 
if  he  is  still  on  the  scene.  It  is  probably  best  for  the  expert 
to  present  the  survey  report  in  person,  as  he  is  responsible 
for  the  work,  and  is  best  fitted  to  answer  any  questions 
that  may  be  asked.  If  the  central  committee  does  not 
number  among  its  members  all  the  important  municipal 
officials  and  representatives  of  all  departments  which  have 
been  investigated,  these  persons  should  be  especially  in- 
vited to  be  present,  so  that  they  may  hear  the  report  at 
first  hand  and  have  an  opportunity  to  be  heard,  should 
they  so  desire. 

It  may  be  possible  to  introduce  the  recommendations 
through  the  central  committee  acting  in  cooperation  with 
the  municipal  officials  and  the  heads  of  departments  which 
were  investigated.  In  a  small  community  this  method  is 
likely  to  be  the  best  to  pursue.  Frequent  meetings  may 
be  arranged  between  selected  representatives  of  the  central 
committee,  and  the  city  officials  and  others  affected  by  the 
survey.  At  these  meetings,  the  findings  and  recommen- 
dations of  the  survey  may  be  studied  more  carefully,  and 
a  plan  may  be  worked  out  for  introducing  the  most  urgently 
needed  reforms.  The  recommendations  of  a  public  health 
survey  are  usually  so  numerous  and  far-reaching  that  it  is 
impossible  to  introduce  the  entire  program  of  reform  at 
one  time.  In  such  cases,  the  most  essential  recommenda- 
tions should  be  introduced,  and  those  that  are  of  minor 
importance  will  usually  follow  in  the  wake  of  the  more 
important  ones. 

Special  Committee  to  Introduce  Recommendations  may 
be  Necessary.  —  Where  the  community  is  large,  and  the 
report  necessarily  voluminous  and  complex,  it  may  be 
undesirable  to  place  in  the  hands  of  a  small  committee 
the  problem  of  introducing  all  the  recommendations  made 
in  the  survey  report.  In  some  cases  it  has  been  found 
desirable  to   divide  the  report  according  to  the  subjects 


354  METHODS  OF  OBTAINING  RESULTS 

considered,  and  to  appoint  a  separate  committee  to  study 
each  subject.  In  such  cases,  each  sub-committee  should 
be  composed  of  men  and  women  who  are  particularly 
interested  in  the  work  under  consideration,  and  who  may 
or  may  not  be  members  of  the  central  committee. 

Sometimes  it  is  desirable  to  have  the  Chamber  of  Com- 
merce assume  the  responsibility  of  introducing  the  recom- 
mendations. In  that  event  the  committees  can  be  chosen 
from  among  the  members  of  this  body;  but  the  central 
committee  should  be  given  adequate  representation  on  all 
sub-committees,  as  its  members  have  been  in  constant 
touch  with  the  survey  from  its  very  inception.  The 
work  of  coordinating  the  activities  of  all  the  committees 
should  be  placed  in  the  hands  of  one  man  who  is  particu- 
larly fitted  for  the  task. 

Each  committee  should  meet  frequently.  The  city 
officials  and  others  who  are  affected  by  the  report  should 
be  in  constant  consultation  with  the  committees;  and 
together  they  should  work  out  some  plan  for  introducing 
the  reforms  advocated  in  the  report.  The  great  danger 
lies  in  the  fact  that  the  members  of  the  committee  may 
lack  vision  and  scientific  training.  Because  of  this,  the 
recommendations  of  the  survey  may  be  sidetracked  or 
modified,  and  action  taken  along  lines  which  are  not 
advocated  in  the  report.  It  is  therefore  apparent  that 
somebody  who  is  adequately  trained  and  who  is  entirely 
familiar  with  the  recommendations  made  in  the  report, 
should  always  be  on  hand,  to  guide  the  action  of  the  com- 
mittees along  the  sane,  scientific  road  outlined  in  the 
report. 

Publicity  a  Great  Stimulus  toward  Final  Action.  —  Full 
and  complete  publicity  should  be  given  to  the  report  itself, 
and  also  to  the  efforts  of  the  committees  to  introduce  its 
recommendations.  The  newspapers  in  the  community 
will  always  be  found  willing  to  cooperate  in  this  respect, 


full-ti:me  well-trained  health  officer    355 

and  may  publish  either  the  whole  report,  or  extensive 
extracts  from  it.  In  this  manner,  aided  by  editorial  com- 
ment and  photographs,  the  people  will  become  acquainted 
with  the  findings  of  the  survey  and  the  recommendations 
of  the  report.  The  pronounced  public  opinion  thus 
aroused  will  facilitate  the  action  of  those  who  are  trying 
to  introduce  the  recommendations.  The  work  of  the 
committees  should  not  be  too  prolonged.  Whatever 
progress  is  made  should  be  communicated  to  the  public 
through  the  daily  press. 

Full-Time     Well-Trained     Health     Officer     a    Primary 
Recommendation.  —  If  the  community  is  without  a  well- 
trained,  experienced,  and  full-time  health  officer,  the  most 
important  part  of  the  program  of  reform  is  to  have  such 
an  executive  appointed  immediately.     With  such  a  man 
as  a  nucleus,  it  will  be  possible  to  build  up  a  splendid 
machine,  especially  if  the  health  oflacer  is  given  sufficient 
freedom  and  power  to  make  his  own  appointments.     Most 
communities  have  a  nucleus  for  a  health  department;   in 
some  cases  it  will  be  found  to  be  very  satisfactory,  and  in 
others   very   deficient.      In   so   far   as   it   is   possible,   the 
reorganized  health  department  should  be  made  to  include 
the  workers  who  were  employed  before  the  reorganization. 
This  cannot  always  be  arranged,  however.     For  instance, 
if  the  health  officer  is  a  part-time  employee,  who  is  a  prac- 
tising physician  in  the  community,  and  who  has  not  been 
trained  in  public  health  work,  it  will  be  desirable  to  replace 
him  by  a  man  who  is  better  qualified  for  the  position.     It 
is  almost  always  true  that  a  practising  physician,  who  is 
also  the  health  officer,  devotes  comparatively  little  time  to 
the  duties  of  his  office,  while  his  private  practice  rarely 
suffers  because  of  his  public  position.     Therefore,  for  the 
best  interests  of  the  public,  it  is  advisable  that  the  health 
officer  should  be   a  full-time  employee,   and  one  who  is 
specially  trained  and  experiemced  in  the  work. 


356  IMETHODS  OF  OBTAINING  RESULTS 

If  the  health  officer  is  a  full-time  employee,  and  is  trained 
and  experienced,  it  is  evident  that  the  problem  of  re- 
organizing the  health  department  will  be  much  easier. 
Such  a  man  appreciates  the  value  of  a  public  health  diag- 
nostic laboratory;  of  sanitary  inspections  of  food-stores, 
restaurants,  dairy-farms,  milk  plants,  privies,  wells, 
manure-piles  and  other  matters  of  public  health  signifi- 
cance; of  public  health  nurses;  of  school  medical  inspec- 
tion and  nursing;  of  clinics  and  dispensaries  for  tuber- 
culosis, venereal  diseases,  infant  welfare,  prenatal  care, 
and  education  in  dietary  standards  and  the  principles  of 
nutrition;  of  vital  statistics;  of  public  health  education; 
of  control  over  food-handlers;  of  the  use  of  vaccines,  anti- 
toxins and  other  prophylactic  sera;  and  of  the  other  factors 
which  enter  into  the  program  of  a  modern  and  progressive 
health  department.  All  of  these  activities  revolve  about 
the  health  officer,  since  he  is  the  administrative  head  and 
coordinates  all  the  activities  of  his  subordinates.  It  is 
thus  apparent  that  the  health  officer  must  be  the  proper 
person  for  the  position,  and  that  if  this  condition  is  ful- 
filled, the  other  problems  of  the  health  department  should 
not  be  difficult  to  solve. 

Careful  Analysis  of  City  Budget  may  Help  to  Get  In- 
creased Appropriations.  —  If  the  survey  report  recommends 
the  reorganization  of  the  health  department  or  other 
changes  which  require  the  employment  of  new  workers 
and  an  enlargement  of  the  activities  of  the  department, 
it  is  certain  that  the  appropriation  for  health  work  will 
neceSsaril}^  have  to  be  increased.  This  may  be  the  greatest 
obstacle  which  the  committee  on  reorganization  will  have 
to  face.  It  will  usually  be  found  helpful  to  show  that  the 
per  capita  appropriation  for  health  work  is  less  than  the 
standard  set  by  the  American  Public  Health  Association, 
and  less  than  that  made  for  other  municipal  activities, 
particularly  those  which  are  of  minor  importance.     Some- 


CAREFUL   ANALYSIS   OF  CITY   BUDGET  357 

times  more  money  is  spent  for  maintaining  parks,  flushing 
or  lighting  the  streets,  collecting  garbage,  or  maintaining 
the  cemeteries,  than  for  public  health  protection,  while 
the  amounts  spent  for  police  and  fire  protection,  for  water- 
supplies,  for  public  school  education  and  for  other  muni- 
cipal activities  are  almost  always  several  times  as  great 
as  that  spent  in  protecting  the  public  health.  A  graphical 
presentation  of  these  facts  is  always  very  striking  and 
effective,  and  convinces  a  city  council,  more  readily  than 
anything  else,  that  the  protection  of  the  public  health 
must  have  greater  financial  support. 

It  is  also  of  considerable  value  to  show  the  per  capita 
expenditure  for  public  health  protection  in  other  communi- 
ties with  the  same  population.  If  the  communities  are 
business  rivals,  or  are  located  in  the  same  part  of  the 
country,  the  comparison  is  still  more  effective,  especially 
if  the  other  communities  have  greater  per  capita  appro- 
priations. If  it  can  also  be  demonstrated  that  a  greater 
per  capita  appropriation  for  health  work  means  a  reduc- 
tion in  the  general  and  infant  death-rates,  such  an  argu- 
ment will  help  materially  in  obtaining  the  increased 
appropriation.  When  the  city  council  becomes  convinced 
that  the  protection  of  the  public  health  has  been  neglected, 
and  that  a  larger  appropriation  is  necessary  for  adequate 
health  protection,  the  funds  will  be  forthcoming. 

The  rapidity  with  which  the  city  council  will  become 
convinced  depends  on  the  thoroughnes.s  and  accuracy  of 
the  data  that  have  been  collected  during  the  survey,  the 
lucidity  with  which  they  are  presented,  the  strength  of 
the  public  opinion  aroused  in  favor  of  the  reforms  which 
are  advocated,  the  personnel  of  the  committees  which  are 
urging  the  reforms,  the  state  of  the  municipal  treasury, 
and  other,  more  personal  factors  which  are  peculiar  to 
every  individual  situation.  All  the  obstacles  which  beset 
the  path  of  a  refDrmer  persuading  a  community  to  change 


358  METHODS  OF  OBTAINING  RESULTS 

from  a  well-trodden,  customary  path  to  a  new  one,  must 
be  overcome  before  the  recommendations  of  the  survey 
are  actually  introduced.  Once  the  change  has  been  made, 
and  the  reorganized  activities  have  been  placed  under  the 
direction  of  properly  trained  and  qualified  persons,  who 
are  also  men  of  vision,  the  benefits  derived  from  the  sur- 
vey will  be  material  and  lasting.  To  a  community  which 
is  willing  to  make  such  readjustments,  a  public  health 
survey  is  a  distinct  blessing,  for  it  will  save  many  lives 
which  would  otherwise  have  been  lost,  and  will  diminish 
sickness  and  suffering.  What  worthier  task  can  a  com- 
munity undertake  than  that  which  aims  to  diminish  un- 
necessary suffering,  misery,  and  death,  and  to  promote 
and  safeguard  the  general  welfare  of  all  its  people? 


CHAPTER   XXI 

THE  VALUE  OF  THE  PUBLIC  HEALTH  SURVEY  IN 
THE   PUBLIC    HEALTH    CAMPAIGN  * 

Only  Scientific  Surveys  Considered.  —  About  ten  years 
ago,  the  public  health  survey  was  developed  in  this  coun- 
try, as  a  means  of  promoting  public  health  progress. 
During  this  time,  many  surveys  have  been  made,  notably 
those  conducted  under  the  auspices  of  the  Russell  Sage 
Foundation,  the  New  York  Bureau  of  Municipal  Research, 
the  DeUneator,  the  United  States  Public  Health  Service, 
the  various  State  Health  Departments,  and  those  carried 
on  by  independent  investigators,  such  as  Professor  C.-E.  A. 
Winslow  and  Mayo  Tolman.  The  nature  of  the  surveys 
which  have  been  made  has  varied  considerably,  some  be- 
ing original  and  thorough  investigations  while  others  were 
more  superficial  and  lacked  the  necessary  knowledge  to 
form  a  proper  basis  for  recommendations.  As  stated  in 
an  earlier  chapter,  a  pubUc  health  survey  may  be  defined 
as  an  investigation,  conducted  by  a  trained  corps  of  work- 
ers, to  determine  the  exact  status  of  those  conditions  which 
may  directly  or  indirectly  affect  the  health  of  the  commun- 
ity. Only  those  surveys  which  answer  this  description 
are  considered  and  evaluated  in  this  chapter. 

During  the  past  five  years,  the  author  has  conducted 
public  health  surveys  in  Taunton  and  Quincy,  Mass.,  in 
Glen  Ridge,  N.  J.,  and  in  the  following  cities  in  Oklahoma: 
Oklahoma  City,  Tulsa,  Muskogee,  Bartlesville,  Shawnee, 

*  The  substance  of  this  chapter  appeared  as  a  joint  paper  by  the 
author  and  Jules  Schevitz,  in  the  American  Journal  of  Public  Health 

for  February,  1921. 

359 


360      VALUE  OF  PUBLIC  HEALTH  SURVEY 

Enid,  Ardmore,  and  McAlester.  It  is  in  retrospect  that 
an  attempt  is  made  to  estimate  the  value  of  such  en- 
deavors. 

The  Value  of  the  Public  Health  Survey.  —  A  public 
health  survey  may  be  valuable  to  a  community  in  the 
following  ways: 

1.  As  a  force  in  stimulating  active  public  interest  in  the 
conditions  affecting  health; 

2.  As  a  powerful  agent  for  promoting  public  health 
education; 

3.  As  the  best  and  only  means  for  determining  the 
exact  status  of  health  conditions  in  a  community. 

4.  As  a  powerful  weapon  for  introducing  health  reforms. 

Factors  Determining  the  Results  Obtained  from  a  Pub- 
lic Health  Survey.  —  It  will  be  readily  recognized  that  the 
value  of  a  public  health  survey  depends  directly  upon  the 
extent  to  which  the  community  is  organized  for  conduct- 
ing it  and  following  up  its  recommendations.  The  value 
of  a  survey  also  depends  upon  the  auspices  under  which 
it  is  conducted,  some  surveys  being  conducted  under 
official  auspices,  and  including  a  published  report  and 
follow-up  work,  while  others  are  undertaken  merely  for 
the  information  of  the  investigator  The  surveys  of  the 
Rockefeller  Foundation  are  examples  of  the  latter  class, 
having  been  made  primarily  for  the  information  of  that 
body.  The  public  health  surveys  of  Taunton  and  Quincy, 
Mass.,  were  also  made  entirely  for  private  information,  so 
that  few  people  knew  of  their  existence,  except  those  directly 
reached  by  the  investigator  in  his  search  for  information. 
In  these  surveys,  the  investigator  alone  benefited  by  the 
study. 

The  Oklahoma  Pu]:)lic  Health  Surveys,  on  the  other 
hand,  were  thoroughly  organized  and  conducted  under 
popular  auspices,  and  were  planned  with  the  idea  of  re- 
porting and  following  up  the  findings  of  the  survey.     A 


USES  OF   PUBLIC   HEALTH  SURVEYS  361 

central  committee,  composed  of  the  leading  citizens  and 
officials  of  each  city,  was  appointed  to  take  charge  of  each 
local  survey.  The  central  committee  consisted  of  repre- 
sentatives from  the  city  administration,  the  health  de- 
partment, the  board  of  education,  the  charities,  the  news- 
papers, the  various  churches,  the  medical  societies,  the 
voluntary  health  organizations,  the  chamber  of  commerce, 
and  other  business  and  social  interests.  Before  and  during 
the  field  work,  widespread  publicity  was  given  to  the  pur- 
pose and  nature  of  the  survey;  and  an  attempt  was  made 
to  interest  all  the  citizens,  by  means  of  newspaper  stories 
and  editorials,  addresses  to  representative  organizations, 
observance  of  a  Health  Sunday,  and  other  educational 
and  pubHcity  methods.  The  organizations  before  which 
the  surveyor  appeared  in  order  to  explain  the  purpose  and 
scope  of  the  survey,  were  the  business  men's  clubs,  the 
medical  societies,  the  women's  clubs,  the  parent-teacher 
associations,  the  industrial  and  other  organizations.  In- 
terest in  the  publ'c  health,  and  particularly  in  the  survey, 
was  aroused  to  an  unusual  degree  in  this  way.  Much 
was  done  during  the  survey,  both  in  the  public  addresses 
and  through  the  daily  articles  in  the  press,  to  preach 
healthy  living. 

At  the  completion  of  the  survey,  a  preliminary  report 
was  immediately  made  to  the  central  committee.  This 
report  was  read  to  the  assembled  committee,  and  a  copy 
of  it  was  left  in  their  care.  The  report  outlined  briefly 
the  findings  of  the  survey,  and  enumerated  the  most  im- 
portant recommendations.  Later,  a  full  and  complete 
report,  including  tables,  charts,  and  photographs,  was 
made  to  the  central  committee. 

Uses  of  Public  Health  Surveys.  —  It  is .  obvious  from 
what  has  already  been  said,  that  the  public  health  survey 
can  be  a  powerful  agent  in  stimulating  an  enlightened 
public  interest  in  matters  pertaining  to  the  public  health, 


3(32      VALUE  OF  PUBLIC  HEALTH  SURVEY 

and  in  disseminating  knowledge  about  healthy  living,  at  a 
time  when  the  people  are  particularly  receptive  toward 
such  information.  It  is  also  obvious  that  the  public 
health  survey  provides  the  most  effective  means  for  ascer- 
taining the  exact  status  of  the  conditions  affecting  health 
in  the  community.  Health  officers  have  been  preaching 
the  necessity  of  periodic  medical  examinations  for  indi- 
viduals. It  is  equally  necessary  for  communities  to  have 
periodic  health  examinations ;  and,  while  the  examina- 
tions need  not  be  as  frequent  as  in  the  case  of  an  indi- 
vidual, they  must  be  regular  and  thorough.  Doubtless 
the  time  is  coming  when  the  public  health  survey  will  be 
regarded  as  one  of  the  regular,  periodic  duties  of  a  health 
department,  just  as  stock-taking  is  a  regular  function  of 
any  intelligently  operated  business  enterprise. 

Public  Health  Survey  is  Necessary  for  an  Intelligent  and 
Well-Balanced  Health  Program. —  In  order  to  make  the 
best  use  of  the  public  funds  at  his  disposal,  as  well  as  to 
adopt  an  intelligent  and  well-balanced  program,  the  health 
officer  must  be  intimately  acquainted  not  only  with  the 
death-rate  and  the  prevalence  of  disease,  but  also  with 
the  conditions  affecting  the  public  health.  This  informa- 
tion can  only  be  obtained  through  the  agency  of  the 
public  health  survey. 

Public  Health  Surveys  are  of  Value  in  Introducing  Re- 
forms. —  The  large  numl^er  of  public  health  surveys  which 
have  been  made  during  the  past  five  years  is  but  an  indi- 
cation of  their  importance  and  value  in  promoting  the 
public  health  campaign.  Health  workers  will  necessarily 
have  to  use  the  survey  more  and  more  in  the  future,  not 
only  to  get  at  the  facts,  but  to  aid  them  in  moving  the 
public  and  the  officials  of  the  city,  state  and  nation  to 
increased  activity  in  promoting  the  public  health.  The 
Harvard-Technology  School  of  Public  Health  requires 
every  student  to  conduct  a  public  health  survey  and  sub- 


FOLLOW-UP  WORK  363 

mit  a  report  before  obtaining  the  Certificate  of  Public 
Health.  It  does  so  because  it  recognizes  the  great  value 
of  the  public  health  survey,  as  a  practical  test  of  the 
student's  knowledge,  also  because  it  realizes  the  increas- 
ing importance  of  the  public  health  survey  as  a  weapon  of 
the  health  officer  in  ascertaining  the  facts  regarding  the 
health  conditions  in  his  community,  and  finally  because 
the  survey  has  great  value  in  bringing  about  sanitary 
reforms. 

Survey  Recommendations  Furnish  a  Program  for  Future 
Activities.  —  What,  after  all,  are  the  benefits  to  be  derived 
from  the  survey  after  it  is  completed?  First  of  all,  it 
must  be  stated  that  the  results  of  a  public  health  survey 
are  often  intangible  and  very  difficult  to  measure.  In 
many  instances,  the  immediate  results  may  be  practically 
nil,  yet  the  recommendations  may  form  a  program  which, 
as  time  goes  on,  will  be  gradually  carried  out.  An  analy- 
sis of  the  after-effects  of  a  large  number  of  public  health 
surveys  conducted  in  this  country  indicates  clearly  that 
many  of  the  improvements  in  health  administration  fol- 
lowing the  survey  are  due  to  its  stimulating  effect  on 
health  and  other  governmental  authorities. 

Follow-Up  Work  Determines  Post-Survey  Results.  — 
In  general,  the  post-survey  results  depend  on  the  effi- 
ciency and  persistence  of  those  who  are  charged  with  the 
task  of  carrying  out  the  recommendations.  Where  no 
special  effort  is  made  toward  this  end,  few  immediate 
benefits  can  be  expected.  The  experience  of  the  author 
shows  that  with  proper  follow-up  work,  many  recom- 
mendations made  in  the  survey  report  can  be  adopted 
soon  after  the  survey-,  but  that  the  number  of  recom- 
mendations introduced  depends  upon  the  thoroughness  and 
effectiveness  of  the  campaign  for  this  purpose.  It  is  not 
enough  to  collect  the  information  required  for  a  complete 
and  comprehensive  survey  report;  wherever  possible,  post- 


364      VALUE  OF  PUBLIC  HEALTH  SURVEY 

survey  activities  should  be  inaugurated  in  order  to  assure 
tangible  and  lasting  results. 

Results  Obtained  from  Various  Public  Health  Surveys. 
—  In  Glen  Ridge,  for  example,  the  full-time  service  of  a 
well-trained  health  officer  was  secured,  in  accordance  with 
the  recommendations  of  the  survey  report.  In  addition, 
the  investigator  was  asked  to  remain  after  the  survey  was 
over,  in  order  to  remedy  the  defects  that  had  been  brought 
to  light.  By  several  visits  to  the  dairies,  many  important 
sanitary  improvements  were  introduced.  By  means  of 
repeated  inspections  and  educational  work,  fly-breeding 
places  were  practically  abolished.  In  one  case,  it  was 
necessary  to  perform  a  special  experiment  to  prove  that 
flies  come  from  maggots  found  in  manure,  before  the  fly- 
breeding  manure-heap  was  removed. 

In  the  Oklahoma  City  public  health  survey,  the  chamber 
of  commerce  assumed  the  responsibility  of  carrying  out 
the  recommendations  in  the  survey  report.  A  public 
health  committee  of  thirty-five  prominent  business  men 
was  appointed  to  consider  the  findings  of  the  survey  and 
to  confer  with  the  city  health  authorities.  The  commit- 
tee of  thirty-five  was  divided  into  sub-committees  on  water, 
milk,  sewage  and  garbage  disposal,  health  department 
organization,  and  tuberculosis.  These  committees  have 
been  meeting  regularly  for  a  year  and  a  half,*  studying  the 
particular  subjects  assigned  to  them  and  reporting  to  the 
general  committee.  In  one  or  two  instances,  the  sub- 
committee pursued  its  study  even  more  intensively  than 
the  original  survey. 

The  following  are  some  of  the  more  direct  results  of  the 
health  survey  in  Oklahoma  City: 

The  Health  Department  was  reorganized  according  to 
the  plan  recommended  in  the  survey  report,  with  a  slight 
modification.     The  health  officer  in  office  during  the  sur- 

*  October,  1920. 


RESULTS  OBTAINED  365 

vey  was  replaced  by  another,  who  was  more  efficient  and 
better-trained.  The  incompetent  milk  inspector  was  dis- 
charged, and  his  work  assigned  to  the  city  chemist,  who 
is  thoroughly  trained  along  these  lines.  Inspections  and 
analyses  of  the  milk-supply  have  since  been  frequently 
made.  Much  publicity  has  been  given  to  the  laboratory 
findings,  and  reports  indicate  a  steady  improvement  in 
the  quality  of  the  milk-supply.  In  accordance  with  the 
recommendation  of  the  survey,  the  incompetent  and  un- 
trained superintendent  of  the  water-purification  plant  has 
been  replaced  by  one  who  is  trained  for  this  work  and  gives 
all  his  time  to  it.  A  great  improvement  in  the  keeping 
of  the  vital  statistics  has  been  brought  about,  and  the 
City  Health  Department,  in  conjunction  with  other  health 
agencies,  is  now  publishing  a  monthly  health  bulletin. 
Appropriations  for  preventive  health  work  have  increased 
greatly  each  year  and  the  health  officer  has  been  ably 
seconded  in  his  requests  for  funds  by  the  public  health 
committee  of  the  chamber  of  commerce.  Other  improve- 
ments which  might  be  mentioned  are  the  suggested  plan 
for  the  centralization  and  coordination  of  public  health 
nursing  activities,  the  appointment  of  a  full-time  school 
medical  inspector  and  a  much  more  general  interest,  on 
the  part  of  the  public,  in  the  city  health  activities. 

The  following  are  some  of  the  results  obtained  from 
other  public  health  surveys: 

In  1913,  Franz  Schneider,  Jr.,  of  the  Russell  Sage  Foun- 
dation in  New  York,  conducted  a  public  health  survey  of 
Newburgh,  N.  Y.  Newburgh  had  suffered  for  years  from 
an  exceedingly  high  typhoid  fever  death-rate.  As  a  result 
of  the  investigation,  it  was  recommended  that  the  water 
be  chlorinated.  At  first  the  water-board  objected,  but 
after  Mr.  Schneider's  recommendations  were  reinforced  by 
those  of  the  experts  whom  the  board  called  in,  the  water- 
supply  was  treated  with  hypochlorite.     Mr.  John  Ritchie, 


366 


VALUE  OF  PI  BLIC  HEALTH  SURVEY 


Jr.,  Associate  Editor  of  the  American  Journal  of  Public 
Health,  writing  for  the  CUnic,  in  the  Boston  Transcript  * 
for  June  28,  1916,  says,  ''The  survey  report  (of  New- 
burgh)  was  presented  May  7,  1913.  In  June,  the  water- 
board  advised  consumers  to  boil  the  water,  and  in  October 
of  the  same  year,  the  permanent  hypochlorite  plant  was 
authorized."  Mr.  Ritchie  also  quotes  the  following  table, 
showing  that  the  typhoid  death-rate  fell  immediately  after 
the  water  was  disinfected. 


TYPHOID   DEATH-RATES  PER   100,000  POPULATION   FOR 

NEWBURGH,   N.  Y. 


Year. 

Rate. 

Year. 

Rate. 

1908 

1Q0Q 

40.3 

50.8 
46.6 
42.6 

1912 

42.2 

1913 

27.8 

IQIO 

1914 

24.1 

1911 

1915 

20.5 

Shelby  M.  Harrison,  Director  of  Surveys  and  Exhibits 
for  the  Russell  Sage  Foundation,  in  his  pamphlet  on 
''Community  Action  Through  Surveys,"  makes  the  fol- 
lowing statement  concerning  the  results  obtained  from  the 
Springfield,  Illinois,  and  Topeka,  Kansas,  surveys: 

"The  events  which  pretty  clearly  had  their  beginning  in 
survey  recommendations,  —  or  at  any  rate,  the  advances 
made  in  the  community  si7ice  the  survey  —  which  had 
been  specifically  recommended  by  the  survey,  no  matter 
what  other  agencies  had  also  helped,"  are  as  follows: 

*  The  author  is  indebted  for  this  infornuition  and  that  which  follows, 
regarding  Springfield  and  Topoka,  to  Mr.  Shelby  M.  Harrison  of  the 
Russell  Sage  Foundation.     Grateful  acknowledgment  is  hereby  made. 


RESULTS   OBTAINED  367 

For  Springfield,  111. 

1.  ''Infant  Hygiene  Work  started." 

2.  "Announcement  made  of  a  movement  on  foot  for 
new  contagious  disease  hospital  facilities." 

3.  ''The  Tuberculosis  Association  has  reorganized  itself 
and  its  work,  placing  more  emphasis  upon  educational 
features." 

4.  "Free  dispensary  established  at  St.  John's  Hospital." 

5.  "Publication  of  the  results  of  milk  inspection  and 
the  scorings  of  milk  dealers  has  been  started;  and  an 
improvement  in  the  milk  situation  is  claimed." 

6.  "The  lighting,  ventilation  and  general  sanitation  of 
all  schools  have  been  given  attention  and  greatly  im- 
proved. Fire-exit  locks  have  been  placed  on  all  outside 
doors,  and  fire-escapes  on  the  high  schools." 

7.  "The  new  school  buildings  in  course  of  erection  meet 
much  higher  standards  with  respect  to  lighting,  heating, 
ventilation,  and  sanitation." 


For  Topeka,  Kansas 

1.  "Full-time  health  officer,  a  specialist  in  public  health 
and  sanitation,  secured." 

2.  "New  and  more  able  milk  inspector  secured,  and  im- 
provement in  the  milk  situation  reported." 

3.  "Health    department    laboratory,     with    laboratory 
worker,  established." 

4.  "East-side   sewer   system    in    the    largest   unsewered 
area  in  Kansas,  provided  for  and  built.     Cost  $150,000." 

5.  "Development  of  infant  hygiene  work  by  the  Public 
Health  Nursing  Association." 

6.  "First  printed  annual  report  of  the  health  depart- 
ment issued." 


368      VALUE  OF  PUBLIC  HEALTH  SURVEY 

Another  important  example  of  beneficial  results  obtained 
through  the  agency  of  the  public  health  survey  is  the  case 
of  the  Framingham  Community  Health  and  Tuberculosis 
Demonstration.  Although  the  Demonstration  was  pri- 
marily interested  in  the  study  of  tuberculosis,  those  who 
directed  it  assumed  that  general  health  conditions  affect 
the  prevalence  of  this  disease.  One  of  the  things  they  did 
was  to  conduct  a  pul>lic  health  survey  of  Framingham. 

In  a  special  report  to  Surgeon  General  Blue  of  the 
United  States  Public  Health  Service,  made  by  the  Com- 
mittee on  Appraisal,  and  published  by  the  Framingham 
Community  Health  Station  in  October,  1919,  the  Com- 
mittee, which  consisted  of  Dr.  Allan  J.  McLaughHn  as 
chairman,  Professor  C.-E.  A.  Winslow,  as  secretary,  and 
many  other  prominent  public  health  workers,  reported  in 
part  as  follows: 

''Even  more  important,  from  the  practical  standpoint, 
has  been  the  notable  development  of  public  health  work 
in  Framingham  along  a  wide  variety  of  lines.  The  local 
health  department  has  grown  to  be  a  strong  and  effective 
one;  and  the  system  of  medical  inspection  of  school  chil- 
dren, organized  under  the  department  of  education,  rep- 
resents one  of  the  best  examples  of  such  service  to  be 
found  in  the  United  States." 

"It  seems  clear  that  if  the  Framingham  Demonstration 
should  cease  on  January  1,  1920,  the  local  community  will 
have  benefited  materially,  and  many  important  contri- 
butions will  have  been  made  to  the  practical  control  of 
tuberculosis." 

Conclusion.  —  In  addition  to  the  above  specific  values 
that  may  result  from  a  public  health  survey,  we  must 
consider  the  possible  usefulness  of  its  recommendations  as 
the  outline  for  a  plan  of  action  on  the  part  of  the  health 
department,  or  others  interested  in  promoting  the  public 
health.     It  may  be  a  year,  or  even  several  years,  before 


RESULTS  OBTAINED  369 

these  recommendations  are  adopted,  but  they  represent 
a  goal  towards  which  future  action  may  be  directed. 

It  may  be  concluded,  therefore,  that  a  public  health 
survey  is  of  distinct  value  in  the  pubhc  health  campaign, 
but  that  its  worth  depends  on  the  thoroughness  with  which 
the  community  has  been  organized  for  the  survey,  and  the 
perseverance  displayed  by  the  responsible  persons,  until 
that  time,  when  the  recommendations  of  the  survey  are 
actually  put  into  operation. 


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INDEX  OF   SUBJECTS 

Activated  Sludge,  97 
Activities  of  health  department,  228 
Adequacy  of  water-supply,  47 
Analysis  of, 

budget,  298,  356 

milk,  142,  235 

water,  76,  235 
Antitoxins,  235 

Anti-tuberculosis  movement,  257,  346 
Appropriations  for  health  work,  226,  237 
Arrangements  for, 

housing  survey,  2,  22,  24 

laboratory  work,  22 
AsheS;  111 

Bang  system,  257 

Births  and  birth-rates,  288 

Budget,  298-309 

adequate  budget  essential,  298-302 

analysis  of, 

and  increased  appropriations,  356-358 
for  health  expenditures,  302 

comparison  of,  for  per  capita  health  appropriations,  305,  306,  308 

data  on,  in  studying.  303-305 

health  officer  and  adequate,  302 

index  of  public  health  activities,  298 

outline  of  chapter  on,  309 

results  of  budget  studv,  illustrated,  307 
Burial  of  animals,  116,  120 

Central  committee,  34.  35,  352 
Charts, 

city  budget, 
per  capita  appropriation  for  health  conservation,  307 

385 


386  INDEX  OF  SUBJECTS 

Charts,  —  continued 

vital  statistics, 

composition  of  population  by  race  and  sex,  285 
population,  281 
Chemical  coagulation  of, 

sewage,  93 

water,  54 
Cisterns,  70 

Classification  of  food-stores,  according  to  score-card  rating,  168 
Classification  of  milks,  according  to, 

bacterial  content,  149 

fat  content,  152 

lactose  fermenters,  151 

specific  gravity,  151 

temperature,  148 
Climate  and  community,  39,  315 
Clinics,  234,  230,  251 

dental,  213         . 

nutrition,  213 
Cloak-rooms  in  schools,  206 
Collection  of  samples 

for  water  analyses,  71,  73 

for  milk  analyses,  142-146 
Comfort  stations,  232 

Communicable  diseases  and  school  children.  229 
Community 

and  locality,  40,  314 

and  health  survey,  6,  10,  19 
Comparison 

of  per  capita  appropriations,  299,  305 

of  appropriations  for  public  health  activities,  298,  302,  308 

of  health  conservation,  305 
Consumption  of  water,  47 
Contact  filtration,  96 
Contagious  disease  hospital,  228,  236,  244 
Contagious  diseases, 

treatment  of,  245 

Dairies, 

classification  of,  137 

inspection  of,  138 
Data  and  health  survey,  7 


INDEX  OF  SUBJECTS  387 


Day-camps,  272 

Dead  animals,  103,  118,  120 

Definition  of  public  health  survey,  2 

Delivery  of  milk,  130 

Dental  clinics,  213 

Detritus  tanks,  89 

Dilution  of  sewage,  87 

Diphtheria,  291 

Disinfection,  58,  99 

terminal,  228 

in  hospitals,  249,  270 
Disinfectants  and  milk-utensils,  141 
Dispensary  for  tuberculosis,  266 
Disposal  of  sewage,  87,  318,  327 
Distribution  system  for  public  water-supply,  48 
Drinking  faciUties,  232 

of  schools,  203 

Endowed  hospitals,  272 

Filtration, 

contact,  96 

intermittent  sand,  95 

trickling,  96 
Final  report  of  health  survey,  37,  310-323,  352 
Flash  method  of  pasteurization,  126 
Food-handlers 

medical  examination  of,  230 
Food-stores,  164 
Foreword  of  final  report,  313 
Form  card, 

for  house  inspections,  177 

for  morbidity  from  communicable  diseases,  277 

for  report  of  deaths,  279 

Garbage,  109,  113 
General  death-rates,  286 

Handling  of  milk,  130 
Health  centers,  234 
Health  department, 

activities  of,  often  inadequate,  223-225 


388  INDEX  OF  SUBJECTS 

Health  department,  —  continued 
appropriations  for,  237 
often  inadequate,  226 
not  always  properly  used,  226 
clinics  and  contagious  disease  hospitals,  236 
control  of, 

milk-supply,  129 
tuberculosis,  264-272 
cooperation  of  police,  239 
cooperation  with  other  agencies,  238 
health  officer  should  be  trained,  225 
information  from  health  officer  concerning, 

organization  and  personnel  of  board  of  health,  227 
organization  and  personnel  of  health  department,  227 
laboratory  facilities  for, 
diagnostic  tests,  235 
milk-anah'ses,  235 
water-analyses,  235 
outline  of  chapter  on,  240-241 
public  health  education  through, 
the  eye,  233 

chnics  and  health  centers,  234 
other  means,  234 
public  health  nurses,  234 
reasons  for  poor  health  protection,  225 
records  and  reports  of,  234 
sanitary  code  and  activities  of, 

cases  of  communicable  disease,  229 
contagious  disease  hospital,  228 
health  index,  228 
inspection  of, 

houses  and  lodging-houses,  231 
railroad  and  comfort  stations, 
benches,  232 
drinking  facihties, 

bubbling  fountains,  232 
individual  cups,  232 
source  and  safety  of  water-supply,  232 
frequency  ot  inspections,  232 
general  cleanliness,  233 
rubbish-barrels,  233 
screens,  and  urinals,  232 


INDEX   OF   SUBJECTS  389 


Health  department,  —  continued 
segregation,  233 
toilet  facilities,  232 
washing  facilities,  232 
other  stations,  233 
school  hygiene  and  sanitation,  189-208,  209-222 
tables,  charts,  forms,  photographs,  239 
vaccines,  sera,  antitoxins,  236 
Heart  diseases,  291 
Heating  of, 
hospitals,  250 
sanatoria,  270 
schools,  191 
Hogs,  feeding  of,  116,  121 
Hospital  facilities,  242-252 

essential  to  community  health,  242 
hospitals, 

other  than  general  and  contagious  disease,  245 
private,  endowed,  municipal,  246 
survey  of, 
building,  247 
cases,  248 
chnics,  251 

disinfection  and  laundry,  249 
heating  and  ventilation,  250 
kitchen,  250 
laboratory  facilities,  249 
nurses'  traming  school,  251 
operating-room,  249 
sunporches  and  parlors,  251 
wards,  247 
modern  hospital,  powerful  force,  242-244 
outUne  of  chapter  on,  252 
Housing,  170-188 

collecting  data  on,  176-178 
outline  of  chapter  on,  188 
problem  of, 

lack  of  water-supply  and  sewerage,  173 
often  fault  of  people,  174 
overcrowding,  171 
Housing  survey, 

arrangements  for,  22 


390  INDEX  OF  SUBJECTS 

Housing  survey,  —  continued 
tables,  179-187 

Imhoff  tank,  91 

Incineration,  118,  122 

Industry  and  community  health,  39 

Inspections  of, 

food-stores,  164,  165 

public  eating-places,  157-158 

railroad  and  comfort  stations,  232 

residences  and  lodging-houses,  231 
Intermittent  sand  filtration,  95 
Introduction  of  final  report,  313 

Kitchen  in  hospitals,  250,  270 

Laborator}^  analyses  of, 

milk,  146 

water,  71-72 
Laboratory  diagnostic  tests,  235 
Laboratory  facilities,  235,  249,  270 

for  health  survey,  21 
Laundry  and  disinfection,  249,  271 
Lighting  of  classrooms,  205 
Lunchrooms  of  schools,  204 

Malaria,  291 

Manure,  104,  113,  318 

Maps  and  final  report,  323 

Measles,  291 

Measures  for  control  of  tuberculosis,  264 

Meters,  use  of,  in  water-supply,  49 

Methods  of  a  health  survey,  28 

Methods  of  water  treatment,  52 

Midwives,  regulation  of,  228 

Milk-supply,  125-155 

collection  of  samples  of,  142-146 

information  regarding, 
milk  ordinance,  129 
production,  handling  and  delivery  of,  130 

inspection  of, 
dairies,  131-138 


INDEX   OF   SUBJECTS  391 

Milk-supplj%  —  continued 

distributing  dairies,  138-142 

milk,  important  food,  125 

outline  of  chapter  on,  155 

"perfect  pasteurization,"  126 

personal  study  of,  128 

report  on,  153 

results  of  analyses  of,  146-153 

safe  supply  essential,  125 
Morbidity  from  communicable  diseases,  276 
Municipal  hospitals,  246 

Nurses'  training  school,  251 
Nutrition  clinics,  213 

Official  health  surveys,  8,  9 

Open-air  classes,  213 

Open-air  schools,  219,  272 

Operating-room  in  hospitals,  249 

Organization  of  a  community  for  health  survey,  10 

Other  sources  of  water-supply,  61,  65 

Outhne  of, 

chapter  on  city  budget,  309 

chapter  on  health  department,  240 

chapter  on  housing,  188 

chapter  on  milk-supply,  155 

chapter  on  refuse,  124 

chapter  on  restaurants  and  food-stores,  169 

chapter  on  school  hygiene,  222 

chapter  on  school  sanitation,  207 

chapter  on  sewerage  and  sewage-disposal,  101 

chapter  on  tuberculosis,  273 

chapter  on  vital  statistics,  296 

chapter  on  water-supply,  76 

topics  considered  in  a  public  health    survey,  with    index   numbers, 
314-320 
Overcrowding  and, 

disease,  171 

pubHc  health,  173 
Ownership  of  water-supply,  49 

Parochial  schools,  218 
Pasteurization 


392  INDEX   OF  SUBJECTS 

Pasteurization,  —  continued 

flash  method,  126 

"perfect"  method,  126 
People  of  a  community,  42,  314 
"Perfect"  method  of  pasteurization,  126 
Personnel 

for  school  hygiene  work,  213 

of  board  of  health,  227 

of  health  department,  227 
Photographs  and  final  report,  322 
Physical  training  in  schools,  218 
Physician  and  health  officer  compared,  225 
Plain  sedimentation,  89 
Pneumonia,  291 

Population,  statistical  study  of,  282 
Preface  of  final  report,  313 
Preliminar}^  report  of  a  health  survey,  36 
Preparation  of  report,  305 
Pressure  of  public  water-supply,  49 
Private 

health  surveys,  8 

hospitals,  246 

schools,  218 

water  sources,  66 
Privy  problem,  79 
Production  of  milk,  130 
Proof  of  final  report,  321 
Public  eating-places,  156 
Public  health  and  health  department,  223 
Public  health  education  through, 

clinics  and  health  centers,  234 

the  eye,  233 

public  health  nurses,  234 
Pubhc  health  nurses,  229,  234 
Public  health  survey, 

advantage  of  organization,  and  publicity,  9,  351-353 

arrangements  for  making  inspections  during,  33 

definition  of,  2 

final  report  of,  37,  352 

interpretation  of  data  of,  7 

methods  employed  in  making,  28 

methods  for  obtaining  results  from,  351-358 


INDEX  OF   SUBJECTS  393 


Public  Health  Survey, —  continued 
need  for  standardizing,  1 
organization  of  central  committee  after,  35 
organizing  a  community  for,  10 
preliminary  report  of,  36 
private  and  official,  8 
publicity  during,  12,  354 
recording  data  obtained  for,  32 
results  from,  364-367 

Framingham,  Mass.,  368 

Glen  Ridge,  N.  J.,  364 

Newburgh,  N.  Y.,  365 

Oklahoma  City,  Okla.,  364 

Springfield,  111.,  367 

Topeka,  Kan.,  367 
sources  of  information  for,  28 
uses  of,  361-363 
value  of  359-369 
Publicity  and  health  surveys,  12,  354 
Purification  of  water,  52 

Qualifications  of  a  public  health  surveyor,  4 
Quarantine,  228 

Hailroad  stations,  sanitation  of,  252 
Recommendations 
of  final  report,  311 
from  other  survey  reports,  324-350 
budget, 

Bartlesville,  Okla.,  349 
Enid,  Okla.,  349 
New  Haven,  Conn.,  350 
Oklahoma  City,  Okla.,  349 
Shawnee,  Okla.,  350 
health  department, 

Lewiston  and  Auburn,  Me.,  338 
New  Haven,  Conn.,  333-336 
New  Orleans,  La.,  338 
Oklahoma  City,  Okla.,  332 
Springfield,  111.,  336-337 
hospital  facilities, 
Enid,  Okla.,  346 


394  INDEX  OF  SUBJECTS 

Recommendations, —  continued 

Muskogee,  Okla.,  346 

New  Haven,  Conn.,  346 

Oklahoma  City,  Okla.,  345 
housing, 

Bartlesville,  Okla.,  339 

New  Haven,  Conn.,  339 

New  Orleans,  La.,  340 

Oklahoma  City,  Okla.,  339 
milk-supph^, 

Charleston,  W.  Va..  332 

Muskogee,  Okla.,  331 

New  Haven,  Conn.  331 

Oklahoma  City.,  Okla.,  331 

Rockford,  111.,  332 
refuse  collection  and  disposal, 

Bartlesville,  Okla.,  330 

Enid,  Okla.,  330 

Muskogee,  Okla.,  330 

New  Haven,  Conn.,  330 

Oklahoma  City,  Okla.,  329 
restaurants,  lunch  rooms  and  food-stores, 

Muskogee,  Okla.,  338 

Oklahoma  City,  Okla.,  338 
school  hygiene, 

Bartlesville,  Okla.,  344 

Framingham,  Mass.,  345 

Muskogee,  Okla.,  344 

New  Haven,  Conn.,  344 

New  Orleans,  La.,  345 

Oklahoma  City,  Okla.,  343 
school  sanitation, 

Ardmore,  Okla.,  341 

Bartlesville,  Okla.,  342 

Enid,  Okla.,  342 

Framingham,  Mass.,  342 

Muskogee,  Okla.,  341 

New  Orleans,  La.,  343 

Oklahoma  City,  Okla.,  341 
sewerage  and  sewage-disposal, 

Ardmore,  Okla.,  328 

Bartlesville,  Okla.,  327 


INDEX  OF  SUBJECTS  395 


Recommendations, —  continued 
Enid,  Okla.,  328 
McAlester,  Okla.,  328 
Muskogee,  Okla.,  327 
New  Haven,  Conn.,  329 
Oklahoma  City,  Okla.,  327 
Shawnee,  Okla.,  328 
tuberculosis, 

Muskogee,  Okla.,  347 
New  Haven,  Conn.,  347 
New  Orleans,  La.,  347 
Oklahoma  City,  Okla.,  346 
vital  statistics, 

New  Haven,  Conn.,  348 
Oklahoma  City,  Okla.   348 
Portland,  Me.,  349 
Shawnee,  Okla.,  348 
Springfield,  III,  349 
water-supply, 

Bar  ties  ville,  Okla.,  325 
Enid,  Okla.,  326 
McAlester,  Okla.,  326 
Muskogee,  Okla.,  325 
New  Haven,  Conn.,  326 
Oklahoma  City,  Okla.,  324 
Shawnee,  Okla.,  326 
Records  and  reports  of  health  department,  234 
Reduction,  119,  123 
Refuse,  102-124 

collection  and  disposal  of, 
an  engineering  problem,  107 
methods  for  obtaining  data  on,  109 
municipal,  most  satisfactory,  105 
municipal  problem,  102 
nuisance  due  to  faulty,  114 
definition  of,  102 
disposal  of, 

dead  animals,  103 
manure,  104 

slaughter-house  wastes,  104 
snow,  104 
methods  of  garbage  disposal,  113-124 


396  INDEX  OF  SUBJECTS 

Refuse, —  continued 
burial,  120 
dumping  at  sea,  119 
dumping  on  land,  120 
feeding  to  hogs,  121 
incineration,  122 
reduction,  123 
outline  of  chapter  on,  12-1 
Registration  area,  276 
Report  card  for  restaurants,  159-160 
Report,  310-323 

attractive  cover  and  type  essential,  322 

maps  for,  323 

outhne  of  topics  considered  in,  314-317 

detailed  index  of  topics,  317-320 
past  accomphshments  to  he  included  in,  320 
photographs  for,  323 

preface,  foreword  and  introduction  to,  313 
preparation  of  final,  310 
proof  of,  should  be  carefully  read,  321 
should  be  perfect  before  going  to  printer,  321 
third  draft  of,  312 

to  include  summaries  and  recommendations,  311 
Reserve  water-supply,  48 

Restaurants,  lunchrooms  and  food-stores,  156-169 
danger  from  food-handlers  in,  156 
mspection  of  food-stores,  164-168 

form  cards  for,  166 
inspection  of  restaurants,.  158-164 

form  cards  for,  159 
outline  of  chapter  on,  169 
"rush  period"  in,  157 
sanitation  of,  156 
supervision  of,  157 
Rubbish,  111 
Rush  periods  in  restaurants,  157 

Sanatoria,  242,  269 
Sand  filtration, 

slow,  56 

rapid,  57 
Sanitary  code,  228 


INDEX  OF  SUBJECTS  397 


Sanitary  handling  of  food,  230 

Sanitation  of  public  eating-places,  156,  320,  338 

Scarlet  fever,  291 

Scavengers  and  refuse,  106 

Schools, 

open-air,  219-221 
parochial,  218 
private,  218 
School  hygiene,  209-222 

methods  of  obtaining  data  on,  213 

clinics,  217 

personnel,  213 

physical  training,  218 

school  dentist,  217 

school  nurse,  215-217 

school  physician,  214 

teacher,  217 
other  agencies  in,  213 
outline  of  chapter  on,  222 
reasons  for  lack  of,  210 
role  of, 

school  nurse,  209 

school  physician,  209 

teacher,  211-213 
School  sanitation,  189-208 
general  information  on,  206 
heating  and  ventilation  of  classrooms,  191-194 
improvements  in  modern,  194 
of  modern  buildings,  excellent,  189-191 
outline  of  chapter  on,  207-208 
study  of,  196-206 

classrooms,  205 

cloak-rooms,  206 

drinking  facilities,  203 

heating  and  ventilation,  199 

lunch  rooms,  204 

school  building,  199 

toilet  and  washing  facilities,  201-203 
unit  plan,  of  school  buildings,  195 
Score-card  for, 
dairies,  133,  134 
food-stores.  166 


398  INDEX  OF  SUBJECTS 

Score-card, —  continued 
housing  survey,  177 
restaurants,  159,  162 
Screens,  87,  232 
Seats  in  classrooms,  206 
Sedimentation,  53 

plain,  89 
Septic  tank,  91 
Sera,  235 

Sewerage  and  sewage-disposal,  78-101 
character  of,  78 
data  on,  81 

methods  of  sewage  treatment,  87-100 
activated  sludge,  97 
broad  irrigation  or  sewage  farming,  94 
coagulation,  93 
coarse  screens,  87 
detritus  tanks,  88 
dilution,  87 
disinfection,  99 
filtration,  95-96 
contact,  96 
intermittent  sand,  96 
trickling,  96 
fine  screens,  87 
ImhofF  tank,  91 
plain  sedimentation,  88 
septic  tank,  91 
outline  of  chapter  on,  101 
privy  problem,  79 

prompt  removal  of,  municipal  function,  78 
sewer-outfalls,  85 

supervision  of  sewage  treatment  plant,  85 
system  of,  81-85 
map  of,  85 

previous  reports  on,  84 
Slaughter-house  wastes,  104 
Smallpox,  291 
Snow,  104   • 

Sources  of  water-supply,  47,  232 
Specific  death-rates,  290 
Spitting  and  sanitary  code,  230 


INDEX  OF   SUBJECTS  399 

Statistical  study  of  tuberculosis,  258 
Storage  of  water,  59 
Storage  of  water-supply,  47 
Summary  of  final  report,  311 
Surveyor  and  housing  conditions,  25 
Surveyor,  qualifications  of,  4 
Survey,  definition  of,  2 
Surveys, 

and  community,  6,  19 

data  of,  7,  32 

final  report  of,  37 

methods  of,  28 

oflficial,  8,  9 

preliminary  report  of,  36 

private,  8 

and  pubhcity,  13,  354 

and  public  interest,  351 

scope  and  aim  of,  2,  3,  4 

sources  of  information  about,  28,  33 

uses  of,  321 

Tables, 

city  budget, 

comparison  of  per  capita  expenditures  of  various  cities  for  health 

conservation,  306 
expenditures  for  municipal  activities,  304 
per  capita  expenditures  for  municipal  activities,  304 
per  cent  distribution  of  total  municipal  expenses,  308 
food-stores, 

classification  of,  according  to  score-card  rating,  168 
kind  and  number  inspected,  168 
housing, 

showing  condition  of  natural  lighting  and  size  of  rooms,  by  wards, 

185 
showing  distribution  of  homes  according  to  color  of  residents,  by 

wards,  187 
showing  height  of  dwellings  and  number  of  families  per  house, 

by  wards,  179 
showing  kind  of  dwelling,  construction,  and  condition,  by  wards, 

180 
showing  method  of  garbage  disposal,  by  wards,  187 
showing  method  of  sewage-disposal,  by  wards,  186 


400  INDEX  OF   SUBJECTS 

Tables, —  continued 

showing  number  of  bedrooms  in  each  home,  by  wards,  184 

showing  number  of  persons  per  family,  by  wards,  181 

showing  number  of  rooms  per  house,  by  wards,  182 

showing  relationship  of  number  per  family  and  number  of  rooms 

occupied,  by  wards,  183 
showing  source  of  drinking  water,  by  wards,  186 

milk-supply, 

chemical  and  bacteriological  analyses  of  milks,  147 
classification  of  dairies  according  to  score-card  ratings,  137 
classification  of  milks  according  to  bacterial  content,  149 
classification  of  milks  delivered  by  producers,  according  to  bacterial 

content,  150 
classification  of  milks  according  to  fat-content,  152 
classification  of  milks  according  to  fermenters  present,  151 
classification  of  milks  according  to  specific  gravity,  151 
classification  of  milks  according  to  temperature  on  arrival,  148 
dairies,  milk  produced,  score-card  rating,  tuberculin  test,  136 
quantity  of  milk  handled,  and  methods  employed,  152 

school  hygiene, 

medical  inspection  of  school  children,  221 

school  sanitation, 

summary  of  inspection  of  school  buildings,  207 

sewerage, 

name,  location,  length  and  size  of  sewers,  100,  101 

tuberculosis, 

cases,  deaths,  and  death-rates,  260 

distribution  of  deaths  according  to  age,  263 

distribution  of  death-rates  according  to  color,  261 

distribution  of  death-rates  according  to  nationahty,  261 

distribution  of  deaths  according  to  occupation,  264 

percentage  deaths  from   all  forms  of  tuberculosis,   according  to 

nationality,  263 
results  of  dispensary  examinations,   classified  according  to  age, 
sex,  and  stage  of  disease,  268 

vital  statistics, 

births  and  birth-rates,  289 

composition  of  population,  according  to  color,  284 

composition  of  population  according  to  sex,  286 

deaths  and  general  death-rat€S,  287 

infant  deaths,  and  death-rates,  290 

population,  283 


INDEX  OF   SUBJECTS  401 

Tables, —  continued 
specific  diseases, 

diphtheria,  cases,  deaths  and  specific  death-rates,  293 
malaria,  cases,  deaths  and  specific  death-rates,  292 
measles,  cases,  deaths  and  specific  death-rates,  294 
organic  heart  diseases,  deaths  and  specific  death-rates,  296 
pneumonia,  cases,  deaths  and  specific  death-rates,  291 
scarlet  fever,  cases,  deaths  and  specific  death-rates,  293 
smallpox,  cases,  deaths  and  specific  death-rates,  295 
typhoid  fever,  cases,  deaths  and  specific  death-rates,  292 

specific  death-rates  for  Newburgh,  N.  Y.,  366 
whooping  cough,  cases,  deaths  and  specific  death-rates,  294 

water-supply, 

chemical  and  bacteriological  analyses  of  other  communal  supplies, 

75 
chemical  and  bacteriological  analyses  of  public  supply,  74 
examination  of  private  sources  of  supply,  76 
Tastes  and  odors,  in  water,  60 
Teacher  and  child  health,  211,  217 
Terminal  disinfection,  228 
Toilet  facilities  of  railroad  stations,  232 
Toilet  facilities  of  schools,  201 
Training  school  for  nurses,  251 
Transportation  of  water  samples,  71 
Treatment  and  supervision  of  water-supply,  48 
Trickling  filtration,  96 
Tuberculosis,  253-274 

anti-tuberculosis  movement,  257 
"great  white  plague,"  253 
measures  for  control  of,  264-272 
day  camps,  272 
education,  272 
open-air  schools,  272 
tuberculosis  dispensary,  264-269 
tuberculosis  sanatorium, 
building,  269 
cases,  270 

disinfection  and  laundry,  271 
heating  and  ventilation,  271 
kitchen,  272 
laboratory  facilities,  271 
wards  and  beds,  269 


402  INDEX  OF  SUBJECTS 

Tuberculosis, —  continued 

methods  of  spreading  infection,  255-257 
methods  of  stud3dng  situation,  258 

statistical,  258-26-1 
outline  of  chapter  on,  273-274 
public  health  problem,  254 

Unit  plan  for  schools,  195 
Urinals  in  railroad  stations,  252 
Uses  of  public  health  surveys,  361 

Vaccines  and  health  department,  256 
Value  of  public  health  survey,  359 
Ventilation  of, 
hospitals,  250 
sanatoria,  270 
schools,  191 
Vital  statistics,  275-297 
law  governing,  281 

methods  for  judging  reporting  of,  276-279 
must  be  accurate  ami  complete,  275 
outline  of  chapter  on,  296-297 
registration  areas  for,  276 
responsibility  for,  280 
study  of, 

for  five  year  period,  280 
graphically  illustrated,  280 
original  death  certificates,  279 
points  to  be  included  in, 

births  and  birth-rates,  288-290 
general  death-rates,  286-287 
population,  282-286 
specific  diseases,  290-296 

Washing  facilities,  232 

of  schools,  201 
Water-supply,  44-77 

adequacy  of,  47 

adequate  supply  and  cleanliness,  45 

consumption,  47 

development  of  municipal,  44 

distribution  system  for,  48 


INDEX  OF   SUBJECTS  403 


Water  supply, —  continued 

inspection  of  purification  plant,  49 

intake,  52 

laboratory  analyses  of,  70-76 

maps  of  system  and  purification  plant,  46 

metering  of,  49 

method  of  reaching  city,  47 

methods  of  treatment,  52-59 

chemical  coagulation,  54 

disinfection,  58 

filtered  water  basin  or  storage,  59 

rapid  sand  filtration,  57 

sedimentation,  53 

slow  sand  filtration,  56 
need  of  adequate  and  safe  supply,  44 
other  communal  supphes,  61-66 

danger  from,  62 

inspection  of,  65 
outline  of  chapter  on,  76 
ownership  of,  49 
portion  of  city  supplied  with,  49 
pressure,  49 
private  supplies,  66-70 

cisterns,  70 

wells,  69 
reserve  supplies,  48 
source  of,  47 
storage  of,  47 
tastes  and  odors  in,  60 
treatment  and  supervision  of,  48 
watershed,  50 
Wells,  69 

Whooping  cough,  291 
Window  shades  of  classrooms,  205 


RA 


570074 


Endneenng 
Library 


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